a health maintenance organization (high, standard, and basic … · 2019-10-13 · northern...

Kaiser Foundation Health Plan of Coloradowww.kp.org/feds

Member Services: 303-338-3800 or toll-free 800-632-9700 (Denver/Boulder); 844-201-5824 (Northern Colorado); 888-681-7878 (Southern Colorado)

2020 A Health Maintenance Organization (High, Standard, and Basic Options)

IMPORTANT • Rates: Back Cover • Changes for 2020: 5 • Summary of Benefits: Page 99

This plan's health coverage qualifies as minimum essential coverage and meets the minimum value standard for the benefits it provides. See page 8 for details. This plan is accredited. See page 13.

Serving: Metropolitan Denver/Boulder, Northern Colorado, and Southern Colorado areas

Enrollment in this Plan is limited. You must live or work in our geographic service area to enroll. See page 14 for requirements.

Enrollment codes for this Plan:

651 High Option - Self Only 653 High Option - Self Plus One 652 High Option - Self and Family

654 Standard Option - Self Only 656 Standard Option - Self Plus One 655 Standard Option - Self and Family

N41 Basic Option - Self Only N43 Basic Option - Self Plus One N42 Basic Option - Self and Family

RI 73-019

Important Notice from Kaiser Foundation Health Plan of Colorado About Our Prescription Drug Coverage and Medicare

The Office of Personnel Management (OPM) has determined that Kaiser Foundation Health Plan of Colorado’s prescription drug coverage is, on average, expected to pay out as much as the standard Medicare prescription drug coverage will pay for all plan participants and is considered Creditable Coverage. This means you do not need to enroll in Medicare Part D and pay extra for prescription drug coverage. If you decide to enroll in Medicare Part D later, you will not have to pay a penalty for late enrollment as long as you keep your FEHB coverage.

However, if you choose to enroll in Medicare Part D, you can keep your FEHB coverage and your FEHB plan will coordinate benefits with Medicare, but you still need to follow the rules in this brochure for us to cover your prescriptions. We will only cover your prescription if it is written by a Plan provider and obtained at a Plan pharmacy or through our Plan mail service delivery program, except in an emergency or urgent care situation.

Remember: If you are an annuitant and you cancel your FEHB coverage, you may not re-enroll in the FEHB Program.

Please be advised

If you lose or drop your FEHB coverage and go 63 days or longer without prescription drug coverage that’s at least as good as Medicare’s prescription drug coverage, your monthly Medicare Part D premium will go up at least 1% per month for every month that you did not have that coverage. For example, if you go 19 months without Medicare Part D prescription drug coverage, your premium will always be at least 19 percent higher than what many other people pay. You will have to pay this higher premium as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the next Annual Coordinated Election Period (October 15 through December 7) to enroll in Medicare Part D.

Medicare’s Low Income Benefits

For people with limited income and resources, extra help paying for a Medicare prescription drug plan is available. Information regarding this program is available through the Social Security Administration (SSA) online at www.socialsecurity.gov, or call the SSA at 800-772-1213 (TTY: 800-325-0778).

You can get more information about Medicare prescription drug plans and the coverage offered in your area from these places:

• Visit www.medicare.gov for personalized help.

• Call 800-MEDICARE (800-633-4227), TTY: 877-486-2048

Table of Contents

Table of Contents ..........................................................................................................................................................................1 Introduction ...................................................................................................................................................................................3 Plain Language ..............................................................................................................................................................................3 Stop Health Care Fraud! ...............................................................................................................................................................3 Discrimination is Against the Law ................................................................................................................................................5 Preventing Medical Mistakes ........................................................................................................................................................5 FEHB Facts ...................................................................................................................................................................................8

Coverage information .........................................................................................................................................................8 • No pre-existing condition limitation ...............................................................................................................................8 • Minimum essential coverage (MEC) ..............................................................................................................................8 • Minimum value standard ................................................................................................................................................8 • Where you can get information about enrolling in the FEHB Program .........................................................................8 • Types of coverage available for you and your family ....................................................................................................8 • Family member coverage ...............................................................................................................................................9 • Children’s Equity Act ...................................................................................................................................................10 • When benefits and premiums start ................................................................................................................................11 • When you retire ............................................................................................................................................................11 When you lose benefits .....................................................................................................................................................11 • When FEHB coverage ends ..........................................................................................................................................11 • Upon divorce ................................................................................................................................................................12 • Temporary Continuation of Coverage (TCC) ...............................................................................................................12 • Converting to individual coverage ...............................................................................................................................12 • Health Insurance Marketplace ......................................................................................................................................12

Section 1. How This Plan Works ................................................................................................................................................13 General features of our High, Standard and Basic Options ..............................................................................................13 How we pay providers ......................................................................................................................................................13 Your rights and responsibilities .........................................................................................................................................13 Your medical and claims records are confidential ............................................................................................................14 Language Interpretation Services ......................................................................................................................................14 Service Area ......................................................................................................................................................................14

Section 2. Changes for 2020 .......................................................................................................................................................15 Section 3. How You Get Care .....................................................................................................................................................16

Identification cards ............................................................................................................................................................16 Where you get covered care ..............................................................................................................................................16

• Plan providers .....................................................................................................................................................16 • Plan facilities ......................................................................................................................................................16

What you must do to get covered care ..............................................................................................................................17 • Primary care ........................................................................................................................................................17 • Specialty care ......................................................................................................................................................17 • Hospital care .......................................................................................................................................................18 • If you are hospitalized when your enrollment begins .........................................................................................18

You need prior Plan approval for certain services ............................................................................................................18 • Non-urgent care claims .......................................................................................................................................20 • Urgent care claims ..............................................................................................................................................20 • Concurrent Care Claims .....................................................................................................................................20 • Emergency services/accidents and post-stabilization care .................................................................................21 • If your treatment needs to be extended ...............................................................................................................21

What happens when you do not follow the precertification rules .....................................................................................21

1 2020 Kaiser Foundation Health Plan of Colorado Table of Contents

Circumstances beyond our control ....................................................................................................................................21 If you disagree with our pre-service claim decision .........................................................................................................21

• To reconsider a non-urgent care claim ................................................................................................................21 • To reconsider an urgent care claim .....................................................................................................................21 • To file an appeal with OPM ................................................................................................................................22

The Federal Flexible Spending Account Program – FSAFEDS .......................................................................................22 Section 4. Your Cost for Covered Services .................................................................................................................................23

Cost-sharing ......................................................................................................................................................................23 Copayments .......................................................................................................................................................................23 Deductible .........................................................................................................................................................................23 Coinsurance .......................................................................................................................................................................23 Your catastrophic protection out-of-pocket maximum .....................................................................................................23 Carryover ..........................................................................................................................................................................24 When Government facilities bill us ..................................................................................................................................24

Section 5. High, Standard and Basic Option Benefits ................................................................................................................25 Section 5. High, Standard and Basic Option Benefits Overview ......................................................................................27 Non-FEHB Benefits Available to Plan Members .............................................................................................................77

Section 6. General Exclusions – Services, Drugs and Supplies We Do Not Cover ....................................................................78 Section 7. Filing a Claim for Covered Services .........................................................................................................................79 Section 8. The Disputed Claims Process .....................................................................................................................................81 Section 9. Coordinating Benefits with Medicare and Other Coverage .......................................................................................84

When you have other health coverage ..............................................................................................................................84 • TRICARE and CHAMPVA ..........................................................................................................................................84 • Workers’ Compensation ................................................................................................................................................84 • Medicaid .......................................................................................................................................................................84 • When other Government agencies are responsible for your care .................................................................................84 • When third parties cause illness or injuries ..................................................................................................................85 • Surrogacy Agreements ..................................................................................................................................................86 • When you have Federal Employees Dental and Vision Insurance Plan (FEDVIP) coverage ......................................86 • Clinical trials .................................................................................................................................................................87 When you have Medicare .................................................................................................................................................87 • What is Medicare? ........................................................................................................................................................87 • Should I enroll in Medicare? ........................................................................................................................................88 • If you enroll in Medicare Part B ...................................................................................................................................88 • The Original Medicare Plan (Part A or Part B) .............................................................................................................88 • Tell us about your Medicare coverage ..........................................................................................................................89 • Medicare Advantage (Part C) .......................................................................................................................................89 • Medicare prescription drug coverage (Part D) .............................................................................................................92

Section 10. Definitions of Terms We Use in This Brochure .......................................................................................................95 Index ............................................................................................................................................................................................98 Summary of Benefits for the High Option of Kaiser Foundation Health Plan of Colorado - 2020 ...........................................99 Summary of Benefits for the Standard Option of Kaiser Foundation Health Plan of Colorado - 2020 ...................................100 Summary of Benefits for the Basic Option of Kaiser Foundation Health Plan of Colorado - 2020 .........................................101 2020 Rate Information for Kaiser Foundation Health Plan of Colorado ..................................................................................102

2 2020 Kaiser Foundation Health Plan of Colorado Table of Contents

Introduction

This brochure describes the benefits of Kaiser Foundation Health Plan of Colorado under our contract (CS 1268) with the United States Office of Personnel Management, as authorized by the Federal Employees Health Benefits law. If you want more information about us, you can call Member Services at 303-338-3800 or toll-free at 800-632-9700 (Denver/Boulder), 844-201-5824 (Northern Colorado), or 888-681-7878 (Southern Colorado), (TTY: 711) or through our website: kp.org. The address for Kaiser Foundation Health Plan of Colorado's administrative office is:

Kaiser Foundation Health Plan of Colorado 2500 South Havana Street Aurora, Colorado 80014-1622

This brochure is the official statement of benefits. No verbal statement can modify or otherwise affect the benefits, limitations, and exclusions of this brochure. It is your responsibility to be informed about your health benefits.

If you are enrolled in this Plan, you are entitled to the benefits described in this brochure. If you are enrolled in Self Plus One or Self and Family coverage, each eligible family member is also entitled to these benefits. You do not have a right to benefits that were available before January 1, 2020, unless those benefits are also shown in this brochure.

OPM negotiates benefits and rates with each plan annually. Benefit changes are effective January 1, 2020, and changes are summarized on page 15. Rates are shown on the last page of this brochure.

Plain Language

All FEHB brochures are written in plain language to make them easy to understand. Here are some examples.

• Except for necessary technical terms, we use common words. For instance, “you” means the enrollee or family member; “we” or "Plan" means Kaiser Foundation Health Plan of Colorado.

• We limit acronyms to ones you know. FEHB is the Federal Employees Health Benefits Program. OPM is the United States Office of Personnel Management. If we use others, we tell you what they mean.

• Our brochure and other FEHB plans’ brochures have the same format and similar descriptions to help you compare plans.

Stop Health Care Fraud!

Fraud increases the cost of health care for everyone and increases your Federal Employees Health Benefits (FEHB) Program premium.

OPM's Office of the Inspector General investigates all allegations of fraud, waste and abuse in the FEHB Program regardless of the agency that employs you or from which you retired.

Protect Yourself From Fraud – Here are some things you can do to prevent fraud:

• Do not give your plan identification (ID) number over the telephone or to people you do not know, except for your health care providers, authorized health benefits plan, or OPM representative.

• Let only the appropriate medical professionals review your medical record or recommend services.

• Avoid using health care providers who say that an item or service is not usually covered, but they know how to bill us to get it paid.

• Carefully review explanations of benefits (EOB) statements that you receive from us.

• Periodically review your claim history for accuracy to ensure we have not been billed for services you did not receive.

• Do not ask your doctor to make false entries on certificates, bills, or records in order to get us to pay for an item or service.

3 2020 Kaiser Foundation Health Plan of Colorado Introduction/Plain Language/Advisory

• If you suspect that a provider has charged you for services you did not receive, billed you twice for the same service, or misrepresented any information, do the following: - Call the provider and ask for an explanation. There may be an error. - If the provider does not resolve the matter, call us at 303-338-3800 or toll-free 800-632-9700 in Denver/Boulder,

844-201-5824 in Northern Colorado, or 888-681-7878 in Southern Colorado, (TTY: 711) and explain the situation. - If we do not resolve the issue:

CALL - THE HEALTH CARE FRAUD HOTLINE 877-499-7295

OR go to

www.opm.gov/our-inspector-general/hotline-to-report-fraud-waste-or-abuse/complaint-form/

The online reporting form is the desired method of reporting fraud in order to ensure accuracy, and a quicker response time.

You can also write to: United States Office of Personnel Management Office of the Inspector General Fraud Hotline

1900 E Street NW Room 6400 Washington, DC 20415-1100

• Do not maintain as a family member on your policy: - Your former spouse after a divorce decree or annulment is final (even if a court order stipulates otherwise) - Your child age 26 or over (unless he/she was disabled and incapable of self-support prior to age 26) - We may request that an enrollee verify the eligibility of any or all family members listed as covered under the enrollee's

FEHB enrollment.

• If you have any questions about the eligibility of a dependent, check with your personnel office if you are employed, with your retirement office (such as OPM) if you are retired, or with the National Finance Center if you are enrolled under Temporary Continuation of Coverage (TCC).

• Fraud or intentional misrepresentation of material fact is prohibited under the Plan. You can be prosecuted for fraud and your agency may take action against you. Examples of fraud include, falsifying a claim to obtain FEHB benefits, trying to or obtaining service or coverage for yourself or for someone else who is not eligible for coverage, or enrolling in the Plan when you are no longer eligible.

• If your enrollment continues after you are no longer eligible for coverage (i.e., you have separated from Federal service) and premiums are not paid, you will be responsible for all benefits paid during the period in which premiums were not paid. You may be billed by your provider for services received. You may be prosecuted for fraud for knowingly using health insurance benefits for which you have not paid premiums. It is your responsibility to know when you or a family member is no longer eligible to use your health insurance coverage.


Discrimination is Against the Law

Kaiser Foundation Health Plan of Colorado complies with all applicable Federal civil rights laws, to include both Title VII of the Civil Rights Act of 1964 and Section 1557 of the Affordable Care Act. Pursuant to Section 1557, Kaiser Foundation Health Plan of Colorado does not discriminate, exclude people, or treat them differently on the basis of race, color, national origin, age, disability, or sex.

You can also file a civil rights complaint with the Office of Personnel Management by mail at:

Office of Personnel Management Healthcare and Insurance Federal Employee Insurance Operations Attention: Assistant Director, FEIO 1900 E Street NW, Suite 3400-S Washington, DC 20415-3610

Preventing Medical Mistakes

Medical mistakes continue to be a significant cause of preventable deaths within the United States. While death is the most tragic outcome, medical mistakes cause other problems such as permanent disabilities, extended hospital stays, longer recoveries, and even additional treatments. Medical mistakes and their consequences also add significantly to the overall cost of healthcare. Hospitals and healthcare providers are being held accountable for the quality of care and reduction in medical mistakes by their accrediting bodies. You can also improve the quality and safety of your own health care and that of your family members by learning more about and understanding your risks. Take these simple steps:

1. Ask questions if you have doubts or concerns.

• Ask questions and make sure you understand the answers.

• Choose a doctor with whom you feel comfortable talking.

• Take a relative or friend with you to help you take notes, ask questions and understand answers.

2. Keep and bring a list of all the medications you take.

• Bring the actual medication or give your doctor and pharmacist a list of all the medications and dosages that you take, including non-prescription (over-the-counter) medications and nutritional supplements.

• Tell your doctor and pharmacist about any drug, food, and other allergies you have, such as to latex.

• Ask about any risks or side effects of the medication and what to avoid while taking it. Be sure to write down what your doctor or pharmacist says.

• Make sure your medication is what the doctor ordered. Ask the pharmacist about the medication if it looks different than you expected.

• Read the label and patient package insert when you get your medication, including all warnings and instructions.

• Know how to use your medication. Especially note the times and conditions when your medication should and should not be taken.

• Contact your doctor or pharmacist if you have any questions.

• Understand both the generic and brand names of your medication. This helps ensure you do not receive double dosing from taking both a generic and a brand. It also helps prevent you from taking a medication to which you are allergic.

3. Get the results of any test or procedure.

• Ask when and how you will get the results of tests or procedures. Will it be in person, by phone, mail, through the Plan or Provider’s portal?


• Don’t assume the results are fine if you do not get them when expected. Contact your healthcare provider and ask for your results.

• Ask what the results mean for your care.

4. Talk to your doctor about which hospital or clinic is best for your health needs.

• Ask your doctor about which hospital or clinic has the best care and results for your condition if you have more than one hospital or clinic to choose from to get the health care you need.

• Be sure you understand the instructions you get about follow-up care when you leave the hospital or clinic.

5. Make sure you understand what will happen if you need surgery.

• Make sure you, your doctor, and your surgeon all agree on exactly what will be done during the operation.

• Ask your doctor, “Who will manage my care when I am in the hospital?”

• Ask your surgeon: - "Exactly what will you be doing?" - "About how long will it take?" - "What will happen after surgery?" - "How can I expect to feel during recovery?"

• Tell the surgeon, anesthesiologist, and nurses about any allergies, bad reactions to anesthesia, and any medications or nutritional supplements you are taking.

Patient Safety Links

For more information on patient safety, please visit:

• www.jointcommission.org/speakup.aspx. The Joint Commission’s Speak Up™ patient safety program.

• www.jointcommission.org/topics/patient_safety.aspx. The Joint Commission helps health care organizations to improve the quality and safety of the care they deliver.

• www.ahrq.gov/patients-consumers/. The Agency for Healthcare Research and Quality makes available a wide-ranging list of topics not only to inform consumers about patient safety but to help choose quality health care providers and improve the quality of care you receive.

• www.npsf.org/. The National Patient Safety Foundation has information on how to ensure safer health care for you and your family.

• www.bemedwise.org. The National Council on Patient Information and Education is dedicated to improving communication about the safe, appropriate use of medication.

• www.leapfroggroup.org/. The Leapfrog Group is active in promoting safe practices in hospital care.

• www.ahqa.org. The American Health Quality Association represents organizations and health care professionals working to improve patient safety.

Preventable Healthcare Acquired Conditions ("Never Events")

When you enter a Plan hospital for a covered service, you do not expect to leave with additional injuries, infections, or other serious conditions that occur during the course of your stay. Although some of these complications may not be avoidable, patients do suffer from injuries or illnesses that could have been prevented if doctors or the hospital had taken proper precautions. Errors in medical care that are clearly identifiable, preventable and serious in their consequences for patients, can indicate a significant problem in the safety and credibility of a health care facility. These conditions and errors are sometimes called “Never Events” or “Serious Reportable Events.” (See Section 10, Definitions of Terms We Use in This Brochure.)


We have a benefit payment policy that encourages Plan hospitals to reduce the likelihood of hospital-acquired conditions such as certain infections, severe bedsores, and fractures, and to reduce medical errors that should never happen. When such an event occurs, neither you nor your FEHB plan will incur costs to correct the medical error. If you are charged a cost share for a never event that occurs while you are receiving an inpatient covered service, or for treatment to correct a never event that occurred at a Plan provider, please notify us.


FEHB Facts

Coverage information

We will not refuse to cover the treatment of a condition you had before you enrolled in this Plan solely because you had the condition before you enrolled.

• No pre-existing condition limitation

Coverage under this plan qualifies as minimum essential coverage (MEC). Please visit the Internal Revenue Service (IRS) website at https://www.irs.gov/affordable-care-act/individuals-and-families/questions-and-answers-on-the-individual-shared-responsibility-provision for more information on the individual requirement for MEC.

• Minimum essential coverage (MEC)

Our health coverage meets the minimum value standard of 60% established by the ACA. This means that we provide benefits to cover at least 60% of the total allowed costs of essential health benefits. The 60% standard is an actuarial value; your specific out-of-pocket costs are determined as explained in this brochure.

• Minimum value standard

See www.opm.gov/healthcare-insurance for enrollment information as well as: • Information on the FEHB Program and plans available to you • A health plan comparison tool • A list of agencies that participate in Employee Express • A link to Employee Express • Information on and links to other electronic enrollment systems.

Also, your employing or retirement office can answer your questions, and give you brochures for other plans and other materials you need to make an informed decision about your FEHB coverage. These materials tell you: • When you may change your enrollment • How you can cover your family members • What happens when you transfer to another Federal agency, go on leave without pay,

enter military service, or retire • What happens when your enrollment ends • When the next Open Season for enrollment begins

We don’t determine who is eligible for coverage and, in most cases, cannot change your enrollment status without information from your employing or retirement office. For information on your premium deductions, you must contact your employing or retirement office.

• Where you can get information about enrolling in the FEHB Program

Self Only coverage is for you alone. Self Plus One coverage is an enrollment that covers you and one eligible family member. Self and Family coverage is for you, and one eligible family member, or your spouse, and your dependent children under age 26, including any foster children authorized for coverage by your employing agency or retirement office. Under certain circumstances, you may also continue coverage for a disabled child 26 years of age or older who is incapable of self-support.

• Types of coverage available for you and your family

8 2020 Kaiser Foundation Health Plan of Colorado FEHB Facts

If you have a Self Only enrollment, you may change to a Self Plus One or Self and Family enrollment if you marry, give birth, or add a child to your family. You may change your enrollment 31 days before to 60 days after that event. The Self Plus One or Self and Family enrollment begins on the first day of the pay period in which the child is born or becomes an eligible family member. When you change to Self Plus One or Self and Family because you marry, the change is effective on the first day of the pay period that begins after your employing office receives your enrollment form. Benefits will not be available to your spouse until you are married. We may request that an enrollee verify the eligibility of any or all family members listed as covered under the enrollee's FEHB enrollment.

Your employing or retirement office will not notify you when a family member is no longer eligible to receive benefits, nor will we. Please tell us immediately of changes in family member status, including your marriage, divorce, annulment, or when your child reaches age 26.

If you or one of your family members is enrolled in one FEHB plan, you or they cannot be enrolled in or covered as a family member by another enrollee in another FEHB plan.

If you have a qualifying life event (QLE) - such as marriage, divorce, or the birth of a child - outside of the Federal Benefits Open Season, you may be eligible to enroll in the FEHB Program, change your enrollment, or cancel coverage. For a complete list of QLEs, visit the FEHB website at www.opm.gov/healthcare-insurance/life-events. If you need assistance, please contact your employing agency, Tribal Benefits Officer, personnel/payroll office, or retirement office.

Family members covered under your Self and Family enrollment are your spouse (including a valid common law marriage) and children as described in the chart below. A Self Plus One enrollment covers you and your spouse, or one eligible family member as described in the chart below.

• Family member coverage


Children Coverage Natural children, adopted children, and stepchildren

Natural, adopted children and stepchildren are covered until their 26th birthday.

Foster children Foster children are eligible for coverage until their 26th birthday if you provide documentation of your regular and substantial support of the child and sign a certification stating that your foster child meets all the requirements. Contact your human resources office or retirement system for additional information.

Children incapable of self-support Children who are incapable of self-support because of a mental or physical disability that began before age 26 are eligible to continue coverage. Contact your human resources office or retirement system for additional information.

Married children Married children (but NOT their spouse or their own children) are covered until their 26th birthday.

Children with or eligible for employer-provided health insurance

Children who are eligible for or have their own employer-provided health insurance are covered until their 26th birthday.

Newborns of covered children are insured only for routine nursery care during the covered portion of the mother's maternity stay.

You can find additional information at www.opm.gov/healthcare-insurance.

OPM has implemented the Federal Employees Health Benefits Children’s Equity Act of 2000. This law mandates that you be enrolled for Self Plus One or Self and Family coverage in the FEHB Program, if you are an employee subject to a court or administrative order requiring you to provide health benefits for your child(ren).

If this law applies to you, you must enroll in Self Plus One or for Self and Family coverage in a health plan that provides full benefits in the area where your children live or provide documentation to your employing office that you have obtained other health benefits coverage for your children. If you do not do so, your employing office will enroll you involuntarily as follows: • If you have no FEHB coverage, your employing office will enroll you for Self Plus

One or Self and Family coverage, as appropriate, in the lowest-cost nationwide plan option as determined by OPM;

• If you have a Self Only enrollment in a fee-for-service plan or in an HMO that serves the area where your children live, your employing office will change your enrollment to Self Plus One or Self and Family, as appropriate, in the same option of the same plan; or

• If you are enrolled in an HMO that does not serve the area where the children live, your employing office will change your enrollment to Self Plus One or Self and Family, as appropriate, in the lowest-cost nationwide plan option as determined by OPM.

• Children’s Equity Act


As long as the court/administrative order is in effect, and you have at least one child identified in the order who is still eligible under the FEHB Program, you cannot cancel your enrollment, change to Self Only, or change to a plan that does not serve the area in which your children live, unless you provide documentation that you have other coverage for the children.

If the court/administrative order is still in effect when you retire, and you have at least one child still eligible for FEHB coverage, you must continue your FEHB coverage into retirement (if eligible) and cannot cancel your coverage, change to Self Only, or change to a plan that does not serve the area in which your children live as long as the court/administrative order is in effect. Similarly, you cannot change to Self Plus One if the court/administrative order identifies more than one child. Contact your employing office for further information.

The benefits in this brochure are effective January 1. If you joined this Plan during Open Season, your coverage begins on the first day of your first pay period that starts on or after January 1. If you changed plans or plan options during Open Season and you receive care between January 1 and the effective date of coverage under your new plan or option, your claims will be paid according to the 2020 benefits of your old plan or option. However, if your old plan left the FEHB Program at the end of the year, you are covered under that plan’s 2019 benefits until the effective date of your coverage with your new plan. Annuitants’ coverage and premiums begin on January 1. If you joined at any other time during the year, your employing office will tell you the effective date of coverage.

If your enrollment continues after you are no longer eligible for coverage, (i.e. you have separated from Federal service) and premiums are not paid, you will be responsible for all benefits paid during the period in which premiums were not paid. You may be billed for services received directly from your provider. You may be prosecuted for fraud for knowingly using health insurance benefits for which you have not paid premiums. It is your responsibility to know when you, or a family member, are no longer eligible to use your health insurance coverage.

• When benefits and premiums start

When you retire, you can usually stay in the FEHB Program. Generally, you must have been enrolled in the FEHB Program for the last five years of your Federal service. If you do not meet this requirement, you may be eligible for other forms of coverage, such as Temporary Continuation of Coverage (TCC).

• When you retire

When you lose benefits

You will receive an additional 31 days of coverage, for no additional premium, when: • Your enrollment ends, unless you cancel your enrollment, or • You are a family member no longer eligible for coverage.

Any person covered under the 31-day extension of coverage who is confined in a hospital or other institution for care or treatment on the 31st day of the temporary extension is entitled to continuation of the benefits of the Plan during the continuance of the confinement but not beyond the 60th day after the end of the 31-day temporary extension.

You may be eligible for spouse equity coverage or Temporary Continuation of Coverage (TCC), or a conversion policy (a non-FEHB individual policy).

• When FEHB coverage ends


If you are divorced from a Federal employee, or annuitant, you may not continue to get benefits under your former spouse’s enrollment. This is the case even when the court has ordered your former spouse to provide health coverage for you. However, you may be eligible for your own FEHB coverage under either the spouse equity law or Temporary Continuation of Coverage (TCC). If you are recently divorced or are anticipating a divorce, contact your ex-spouse’s employing or retirement office to get information about your coverage choices. You can also visit OPM’s website, www.opm.gov/healthcare-insurance/healthcare/plan-information/. We may request that an enrollee verify the eligibility of any or all family members listed as covered under the enrollee’s FEHB enrollment.

• Upon divorce

If you leave Federal service, Tribal employment, or if you lose coverage because you no longer qualify as a family member, you may be eligible for Temporary Continuation of Coverage (TCC). The Patient Protection and Affordable Care Act (ACA) did not eliminate TCC or change the TCC rules. For example, you can receive TCC if you are not able to continue your FEHB enrollment after you retire, if you lose your Federal or Tribal job, if you are a covered dependent child and you turn 26, etc.

You may not elect TCC if you are fired from your Federal or Tribal job due to gross misconduct.

Enrolling in TCC. Get the RI 79-27, which describes TCC from your employing or retirement office or from www.opm.gov/healthcare-insurance. It explains what you have to do to enroll.

Alternatively, you can buy coverage through the Health Insurance Marketplace where, depending on your income, you could be eligible for a new kind of tax credit that lowers your monthly premiums. Visit www.HealthCare.gov to compare plans and see what your premium, deductible, and out-of-pocket costs would be before you make a decision to enroll. Finally, if you qualify for coverage under another group health plan (such as your spouse's plan), you may be able to enroll in that plan, as long as you apply within 30 days of losing FEHB Program coverage.

• Temporary Continuation of Coverage (TCC)

You may convert to a non-FEHB individual policy if: • Your coverage under TCC or the spouse equity law ends (If you canceled your

coverage or did not pay your premium, you cannot convert); • You decided not to receive coverage under TCC or the spouse equity law; or • You are not eligible for coverage under TCC or the spouse equity law.

If you leave Federal or Tribal service, your employing office will notify you of your right to convert. You must contact us in writing within 31 days after you receive this notice. However, if you are a family member who is losing coverage, the employing or retirement office will not notify you. You must contact us in writing within 31 days after you are no longer eligible for coverage.

Your benefits and rates will differ from those under the FEHB Program; however, you will not have to answer questions about your health, a waiting period will not be imposed, and your coverage will not be limited due to pre-existing conditions. When you contact us we will assist you in obtaining information about health benefits coverage inside or outside the Affordable Care Act's Health Insurance Marketplace in your state. For assistance in finding coverage, please contact us at 303-338-3800 or 800-632-9700 (Denver/Boulder), 844-201-5824 (Northern Colorado), or 888-681-7878 (Southern Colorado), or visit our website at kp.org.

• Converting to individual coverage

If you would like to purchase health insurance through the ACA's Health Insurance Marketplace, please visit www.HealthCare.gov. This is a website provided by the U.S. Department of Health and Human Services that provides up-to-date information on the Marketplace.

• Health Insurance Marketplace


Section 1. How This Plan Works

This Plan is a health maintenance organization (HMO). OPM requires that FEHB plans be accredited to validate that plan operations and/or care management meet nationally recognized standards. Kaiser Foundation Health Plan of Colorado holds the following accreditations: National Committee for Quality Assurance (NCQA). To learn more about this plan's accreditation, please visit the following website: www.ncqa.org. We require you to see specific physicians, hospitals, and other providers that contract with us. These Plan providers coordinate your health care services. We are solely responsible for the selection of these providers in your area. Contact us for a copy of our most recent provider directory. We give you a choice of enrollment in a High Option, Standard Option, or Basic Option.

HMOs emphasize preventive care such as routine office visits, physical exams, well-baby care, and immunizations, in addition to treatment for illness and injury. Our providers follow generally accepted medical practice when prescribing any course of treatment.

When you receive services from Plan providers, you will not have to submit claim forms. You only pay the copayments, coinsurance, and deductibles described in this brochure. When you receive emergency services or services covered under the travel benefit, from non-Plan providers, you may have to submit claim forms.

You should join an HMO because you prefer the plan’s benefits, not because a particular provider is available. You cannot change plans because a provider leaves our Plan. We cannot guarantee that any one physician, hospital, or other provider will be available and/or remain under contract with us.

General features of our High, Standard and Basic Options

How we pay providers

We contract with individual providers, medical groups, and hospitals to provide the benefits in this brochure. These Plan providers accept a negotiated payment from us, and you will only be responsible for your cost-sharing (copayments, coinsurance, deductibles, and non-covered services and supplies).

Your rights and responsibilities

OPM requires that all FEHB plans provide certain information to their FEHB members. You may get information about us, our networks, our providers, and our facilities. OPM’s FEHB website (www.opm.gov/healthcare-insurance/) lists the specific types of information that we must make available to you. Some of the required information is listed below.

• We are a health maintenance organization that has provided health care services in the Colorado area since 1969.

• This medical benefit plan is provided by Kaiser Foundation Health Plan of Colorado. Medical and hospital services are provided through our integrated health care delivery organization known as Kaiser Permanente. Kaiser Permanente is composed of Kaiser Foundation Health Plan of Colorado (a not-for-profit organization) and Colorado Permanente Medical Group, P.C., (a for-profit Colorado-based corporation) which operates Plan medical offices throughout the Denver/Boulder, Northern Colorado, and Southern Colorado areas. In the Northern Colorado and Southern Colorado areas, we also offer you services through participating providers.

You are also entitled to a wide range of consumer protections and have specific responsibilities as a member of this Plan. You can view the complete list of these rights and responsibilities by visiting our website, at kp.org/feds. You can also contact us to request that we mail a copy to you.

If you want more information about us, call 303-338-3800 or toll-free 800-632-9700 for Denver/Boulder, 844-201-5824 for Northern Colorado, or 888-681-7878 for Southern Colorado, (TTY: 711), or write to Kaiser Foundation Health Plan of Colorado, Member Services Department, 2500 South Havana Street, Aurora, Colorado 80014-1622. You may also visit our website at kp.org/feds.

By law, you have the right to access your protected health information (PHI). For more information regarding access to PHI, visit our website at kp.org/feds to obtain our Notice of Privacy Practices. You can also contact us to request that we mail you a copy of that Notice.

13 2020 Kaiser Foundation Health Plan of Colorado Section 1

Your medical and claims records are confidential

We will keep your medical and claims records confidential. Please note that we may disclose your medical and claims information (including your prescription drug utilization) to any of your treating providers or dispensing pharmacies.

Language Interpretation Services

Language interpretation services are available to non-English speaking members. Please ask an English-speaking friend or relative to call Member Services at 303-338-3800 or toll-free at 800-632-9700 (Denver/Boulder members), 844-201-5824 (Northern Colorado members), or 888-681-7878 (Southern Colorado members), (TTY: 711).

Service Area

To enroll in this Plan, you must live or work in our service area. This is where our providers practice. Our service area is:

The Denver/Boulder Service Area is that portion of Adams, Arapahoe, Boulder, Broomfield, Clear Creek, Denver, Douglas, Elbert, Gilpin, Jefferson, Larimer, Park, Teller and Weld counties within the following ZIP codes: 80001-07, 80010-27, 80030-31, 80033-38, 80040-42, 80044-47, 80102, 80104, 80107-13, 80116-17, 80120-31, 80134-35, 80137-38, 80150-51, 80155, 80160-63, 80165-66, 80201-12, 80214-39, 80241, 80243-44, 80246-51, 80256-57, 80259-66, 80271, 80273-74, 80281, 80290-91, 80293-94, 80299, 80301-10, 80314, 80401-03, 80419, 80421-22, 80425, 80427, 80433, 80436-37, 80439, 80444, 80452-55, 80457, 80465-66, 80470-71, 80474, 80481, 80501-04, 80510, 80514, 80516, 80520, 80530, 80533, 80540, 80544, 80601-03, 80614, 80621, 80640, 80642-43.

The Northern Colorado Service Area is that portion of Adams, Boulder, Larimer, Morgan, and Weld counties within the following ZIP codes: 69128, 69145, 80511-13, 80515, 80517, 80521-28, 80532, 80534-39, 80541-43, 80545-47, 80549-51, 80553, 80610-12, 80615, 80620, 80622, 80623, 80624, 80631-34, 80638-39, 80644-46, 80648-52, 80654, 80729, 80732, 80742, 80754, 82063, 82070, 82082.

The Southern Colorado Service Area is that portion of Crowley, Custer, Douglas, El Paso, Elbert, Fremont, Huerfano, Las Animas, Lincoln, Otero, Park, Pueblo, and Teller counties within the following ZIP codes: 80106, 80118, 80132-33, 80808-09, 80813-14, 80816-17, 80819-20, 80827, 80829, 80831-33, 80840-41, 80860, 80863-64, 80866, 80901-39, 80941-42, 80946-47, 80949-51, 80960, 80962, 80970, 80977, 80995, 80997, 81001-12, 81019, 81022-23, 81025, 81039, 81062, 81069, 81212, 81215, 81221-23, 81226, 81232-33, 81240, 81244, 81253, 81290.

Ordinarily, you must receive your care from physicians, hospitals, and other providers who contract with us. However, we are part of the Kaiser Permanente Medical Care Program, and if you are visiting another Kaiser Permanente service area, you can receive visiting member services from designated providers in that area. See Section 5(h), Wellness and Other Special Features, for more details. We also pay for certain follow-up services or continuing care services while you are traveling outside the service area, as described in Section 5(h); and for emergency care obtained from any non-Plan provider, as described in Section 5(d), Emergency Services/Accidents. We will not pay for any other health care services.

If you or a covered family member move outside of our service area, you can enroll in another plan. If your dependents live out of the area (for example, if your child goes to college in another state), you should consider enrolling in a fee-for-service plan or an HMO that has agreements with affiliates in other areas. If your dependent is temporarily outside any Kaiser Permanente service area, they may qualify for the dependent out-of-area benefit. See Section 5(h), Wellness and Other Special Features. If you or a family member move, you do not have to wait until Open Season to change plans. Contact your employing or retirement office.


Section 2. Changes for 2020

Do not rely only on these change descriptions; this Section is not an official statement of benefits. For that, go to Section 5 Benefits. Also, we edited and clarified language throughout the brochure; any language change not shown here is a clarification that does not change benefits.

Changes to High, Standard, and Basic Options

• Premium: Your share of the non-Postal premium will increase for Self Only, Self Plus One, or Self and Family. See page 102.

• Service area reduction: We have eliminated Eagle, Garfield, Grand, Rout and Summit counties from our service area. See page 14.

• Preventive care services: To align with the Affordable Care Act: (1) we added perinatal depression counseling and interventions for pregnant and postpartum persons who are at increased risk of perinatal depression to the list of preventive care services covered at no charge; and (2) we removed Vitamin D for the prevention of fractures from the preventive care medications list, so you will pay the applicable drug cost-sharing. See pages 30 and 102.

• Outpatient opioid treatment: We have reduced the copayment for outpatient opioid treatment program from one copayment per visit to one copayment every 30 days. See page 64.

Changes to High Option only

• Part B premium reimbursement: We have implemented a program to reimburse a part of the Medicare Part B premium for members with Medicare. For each month you are enrolled in Kaiser Permanente Senior Advantage 2, you will be reimbursed up to $125 of your Medicare Part B monthly premium. See page 89.

• Emergency room: We increased the emergency room copayment from $200 to $300 per visit. See page 61.

• Hospice care: We changed hospice services to apply to members with a life expectancy of six months or less. See page 58.

• Telehealth services: We decreased the copayment for interactive video visits from $20 per primary care visit and $30 per specialty care visit to no charge. See page 30.

Changes to Standard Option only

• Part B premium reimbursement: We have implemented a program to reimburse a part of the Medicare Part B premium for members with Medicare. For each month you are enrolled in Kaiser Permanente Senior Advantage 2, you will be reimbursed up to $125 of your Medicare Part B monthly premium. See page 89.

• Primary care office procedures: We included the cost-sharing for procedures received during a primary care office visit in the $30 copayment. See page 29 and page 64.

• Emergency room: We increased the emergency room copayment from $300 per visit after the deductible to $350 per visit after the deductible. See page 61.

• Hospice care: We decreased the cost-share for home-based hospice care from 10% after the deductible to no charge. We changed hospice services to apply to members with a life expectancy of six months or less. See page 58.


Changes to Basic Option only

• Deductible: We decreased the deductible from $600 per person ($1,200 per family enrollment) to $500 per person ($1,000 per family enrollment). See page 23.

• Out-of-pocket maximum: We increased the catastrophic out-of-pocket maximum from $6,000 per person (up to $12,000 per family) to $6,500 per person (up to $13,000 per family). See page 23.

• Chiropractic services: We increased the copayment for chiropractic services from $30 to $40 per visit. See page 46.

• Hospice care:We decreased the cost-share for home-based hospice care from 20% after the deductible to no charge. We changed hospice services to apply to members with a life expectancy of six months or less. See page 58.



Section 3. How You Get Care

We will send you an identification (ID) card when you enroll. You should carry your ID card with you at all times. You must show it whenever you receive services from a Plan provider, or fill a prescription at a Plan pharmacy. Providers may request photo identification together with your ID card to verify identity. Until you receive your ID card, use your copy of the Health Benefits Election Form, SF-2809, your health benefits enrollment confirmation letter (for annuitants), or your electronic enrollment system (such as Employee Express) confirmation letter.

If you do not receive your ID card within 30 days after the effective date of your enrollment, or if you need replacement cards, call Member Services at 303-338-3800 or toll-free 800-632-9700 in Denver/Boulder, 844-201-5824 in Northern Colorado, and 888-681-7878 in Southern Colorado, (TTY: 711) or write to us at: Kaiser Foundation Health Plan of Colorado, Member Services, 2500 South Havana Street, Aurora, Colorado 80014-1622. After registering on our website at kp.org/feds, you may also request replacement cards electronically.

Identification cards

You get care from “Plan providers” and “Plan facilities”. You will only pay cost-sharing as defined in Section 10, Definitions of Terms We Use in This Brochure.

Where you get covered care

Plan providers are physicians and other health care professionals in our service area that we contract with to provide covered services to our members. In the Denver/Boulder area, we contract with the Colorado Permanente Medical Group, P.C. (Medical Group), to provide or arrange covered services for our members. In the Northern Colorado and Southern Colorado areas, we contract with the Medical Group and with a panel of affiliated primary care physicians, specialists, and other health care professionals to provide or arrange covered services for our members. Medical care is provided through physicians, nurse practitioners, physician assistants and other skilled medical personnel. Specialists in most major specialties are available as part of the medical teams for consultation and treatment. We credential Plan providers according to national standards.

We list Medical Group providers and affiliated primary care physicians, specialists, and other health care professionals in the provider directory, which we update periodically. Directories are available at the time of enrollment or upon request by calling Member Services at 303-338-3800 or toll-free 800-632-9700 (Denver/Boulder members), 844-201-5824 (Northern Colorado members), or 888-681-7878 (Southern Colorado members), (TTY: 711). The list is also on our website at kp.org/feds.

• Plan providers

Members may get covered routine care from any Plan provider at any Kaiser Permanente medical office and from any affiliated Plan provider in our Denver/Boulder, Northern Colorado, and Southern Colorado service areas.

Plan facilities are hospitals, medical offices, and other facilities in our service area that we own or contract with to provide covered services to our members. Kaiser Permanente offers comprehensive health care with Plan providers conveniently located throughout our Denver/Boulder, Northern Colorado, and Southern Colorado service areas.

We list Plan facilities in the provider directory, with their locations and phone numbers. Directories are updated on a regular basis and are available at the time of enrollment or upon request by calling Member Services at 303-338-3800 or toll-free 800-632-9700(Denver/Boulder members), 844-201-5824 (Northern Colorado members), or 888-681-7878 (Southern Colorado members), (TTY: 711). The list is also on our website at kp.org/feds.

• Plan facilities


You must receive your health services at Plan facilities, except if you have an emergency, authorized referral, or out-of-area urgent care. If you are visiting another Kaiser Permanente service area, you may receive health care services at those Kaiser Permanente facilities. See Section 5(h), Wellness and Other Special Features, for more details. Under the circumstances specified in this brochure, you may receive follow-up or continuing care while you travel anywhere.

It depends on the type of care you need. First, you and each covered family member should choose a primary care provider. This decision is important since your primary care provider provides or arranges for most of your health care.

What you must do to get covered care

We encourage you to choose a primary care provider when you enroll. You may select a primary care provider from any of our available Plan providers who practice in these specialties: internal medicine, pediatrics, or family practice. If you do not select a primary care provider, one may be selected for you. Parents may choose a pediatrician as the primary care provider for their child. Your primary care provider will provide most of your health care, or request a referral for you to see a specialist.

To choose your primary care provider, you can either select one from our provider directory, from our website, kp.org/feds, or you can call our Personal Physician Selection Team at 303-338-4477 toll-free 855-208-7221, (TTY: 711). If you want to receive care from a specific provider who is listed in the directory, call our Personal Physician Selection Team to verify that the provider still participates with the Plan and is accepting new patients.

Please notify us of the primary care provider you choose. If you need help choosing a primary care provider, call us. You may change your primary care provider at any time. You are free to see other Plan providers if your primary care provider is not available, and to receive care at other Kaiser Permanente facilities.

• Primary care

Specialty care is care you receive from providers other than a primary care provider.

You may self-refer for consultation (routine office) visits to Plan specialists except for the anesthesia clinical pain department, and to affiliated specialists identified as eligible to receive self-referrals.

A written authorization from the Plan is required for:

(i) services in addition to those provided as part of the routine office visit, such as surgery and specialty procedures;

(ii) visits to Plan specialists not eligible to receive self-referrals; and

(iii) affiliated specialists.

You will find the specialists eligible to receive self-referrals listed in the Member Resource Guide which is available on our website, kp.org/feds or you may obtain a paper copy by calling Member Services at 303-338-3800 or toll-free 800-632-9700 (Denver/Boulder), 844-201-5824 (Northern Colorado members), or 888-681-7878 (Southern Colorado members), (TTY: 711).

Here are some other things you should know about specialty care: • If you need to see a specialist frequently because of a chronic, complex, or serious

medical condition, your primary care provider, in consultation with you and your attending specialist, may develop a treatment plan that allows you to see your specialist for a certain number of visits without additional referrals. Your primary care provider will use our criteria when creating your treatment plan (the provider may have to get an authorization or approval beforehand).

• Specialty care


• If you are seeing a specialist when you enroll in our Plan, talk to your primary care provider. Your primary care provider will decide what treatment you need. If he or she decides to refer you to a specialist, ask if you can see your current specialist. If your current specialist does not participate with us, you must receive treatment from a specialist who does. Generally, we will not pay for you to see a specialist who does not participate with our Plan.

• If you are seeing a specialist and your specialist leaves the Plan, call your primary care provider, who will request for you to see another specialist. You may receive approved services from your current specialist until we can make arrangements for you to see a Plan specialist.

• If you have a chronic and disabling condition and lose access to your specialist because we: - terminate our contract with your specialist for a reason other than cause; - drop out of the Federal Employees Health Benefits (FEHB) Program and you

enroll in another FEHB plan; or - reduce our service area and you enroll in another FEHB plan;

you may be able to continue seeing your specialist for up to 90 days after you receive notice of the change. Contact us or, if we drop out of the Program, contact your new plan.

If you are in the second or third trimester of pregnancy and you lose access to your specialist based on the above circumstances, you can continue to see your specialist until the end of your postpartum care, even if it is beyond the 90 days.

Your Plan primary care provider or specialist will make necessary hospital arrangements and supervise your care. This includes admission to a skilled nursing or other type of facility.

• Hospital care

We pay for covered services from the effective date of your enrollment. However, if you are in the hospital when your enrollment in our Plan begins, call our Member Services Department immediately at 303-338-3800 or toll-free at 800-632-9700 (Denver/Boulder members), 844-201-5824 (Northern Colorado members), or 888-681-7878 (Southern Colorado members), (TTY: 711). If you are new to the FEHB Program, we will arrange for you to receive care and provide benefits for your covered services while you are in the hospital beginning on the effective date of your coverage.

If you changed from another FEHB plan to us, your former plan will pay for the hospital stay until: • you are discharged, not merely moved to an alternative care center; • the day your benefits from your former plan run out; or • the 92nd day after you become a member of this Plan, whichever happens first.

These provisions apply only to the benefits of the hospitalized person. If your plan terminates participation in the FEHB Program in whole or in part, or if OPM orders an enrollment change, this continuation of coverage provision does not apply. In such cases, the hospitalized family member’s benefits under the new plan begin on the effective date of enrollment.

• If you are hospitalized when your enrollment begins

Your primary care provider arranges most referral requests to specialists. For certain services your Plan provider must obtain approval from us. Before we approve a referral request, we may consider if the service or item is medically necessary and meets other coverage requirements. We call this review and approval process "prior authorization". If the referral request is approved, we will notify you that we have authorized your referral request.

Your Plan provider must obtain prior authorization for:

You need prior Plan approval for certain services


• Inpatient hospital care services, surgery and procedures • Outpatient surgery, related services and procedures • Ambulance transport (non-emergency) • Applied Behavior Analysis (ABA) Therapy • Bariatric surgery, Lap band (adjustable gastric band fills) and related services • Biofeedback • Certain prescription medications as identified on our formulary • Dietary consultations • Durable medical equipment (DME) and orthopedic and prosthetic devices • Genetic testing and counseling • Initial evaluation for eligibility and acceptance into a clinical trial • Injections/Infusions • Implantable devices • Home health services and hospice care • Infertility diagnosis and treatment • Insulin pumps/supplies and continuous glucose monitoring • Medical dental services including oral maxillary services and temporomandibular joint

treatment • Neuropsychological testing • Organ/tissue transplants and related services • Outpatient physical therapy, occupational therapy, speech therapy, and cardiac

rehabilitation • All perinatal monitoring services • The following radiology services:

- MRI - PET scans - CT scans - Nuclear imaging studies

• Prenatal diagnostic tests outside of the doctor’s office • Skilled nursing care • The following treatment therapies:

- Infusion therapy - Hyperbaric oxygen therapy - Pulmonary rehabilitation - Pain management services - Sclerotherapy for varicose veins

• Transgender surgical services • Weight loss clinic • Services or items from a non-Colorado Permanente Medical Group provider, a non-

Plan provider or at non-Plan facilities

To confirm if a referral request has been approved for a service or item that requires prior authorization, please call our Member Services Department at 303-338-3800 or toll-free 800-632-9700 in Denver/Boulder, 844-201-5824 in Northern Colorado, or 888-681-7878 in Southern Colorado, (TTY: 711).


Your Plan provider submits the request for the services above with supporting documentation. You should call Member Services if you have not been notified of the outcome of the review within 15 calendar days. If your referral request is not approved, you have the right to ask us in writing to reconsider our initial decision (see Section 8, The Disputed Claims Process).

Prior authorization determinations are made based on the information available at the time the service or item is requested. We will not cover the service or item unless you are a Plan member on the date you receive the service or item.

For non-urgent care claims, we will tell the provider and/or hospital the number of approved inpatient days, or the care that we approve for other services that must have prior authorization. We will make our decision within 15 days of receipt of the pre-service claim. If matters beyond our control require an extension of time, we may take up to an additional 15 days for review and we will notify you of the need for an extension of time before the end of the original 15-day period. Our notice will include the circumstances underlying the request for the extension and the date when a decision is expected.

If we need an extension because we have not received necessary information from you, our notice will describe the specific information required and we will allow you up to 60 days from the receipt of the notice to provide the information.

• Non-urgent care claims

If you have an urgent care claim (i.e., when waiting for the regular time limit for your medical care or treatment could seriously jeopardize your life, health, or ability to regain maximum function, or in the opinion of a physician with knowledge of your medical condition, would subject you to severe pain that cannot be adequately managed without this care or treatment), we will expedite our review and notify you of our decision within 72 hours. If you request that we review your claim as an urgent care claim, we will review the documentation you provide and decide whether or not it is an urgent care claim by applying the judgment of a prudent layperson that possesses an average knowledge of health and medicine.

If you fail to provide sufficient information, we will contact you within 24 hours after we receive the claim to let you know what information we need to complete our review of the claim. You will then have up to 48 hours to provide the required information. We will make our decision on the claim within 48 hours of (1) the time we received the additional information or (2) the end of the time frame, whichever is earlier.

We may provide our decision orally within these time frames, but we will follow up with written or electronic notification within three days of oral notification.

You may request that your urgent care claim on appeal be reviewed simultaneously by us and OPM. Please let us know that you would like a simultaneous review of your urgent care claim by OPM either in writing at the time you appeal our initial decision, or by calling us at 303-344-7933 or toll-free at 888-370-9858, (TTY: 711). You may also call OPM’s FEHB 3 at 202-606-0755 between 8 a.m. and 5 p.m. Eastern Time to ask for the simultaneous review. We will cooperate with OPM so they can quickly review your claim on appeal. In addition, if you did not indicate that your claim was a claim for urgent care, call us at 303-344-7933 or toll-free at 888-370-9858, (TTY: 711). If it is determined that your claim is an urgent care claim, we will expedite our review (if we have not yet responded to your claim).

• Urgent care claims

A concurrent care claim involves care provided over a period of time or over a number of treatments. We will treat any reduction or termination of our pre-approved course of treatment before the end of the approved period of time or number of treatments as an appealable decision. This does not include reduction or termination due to benefit changes or if your enrollment ends. If we believe a reduction or termination is warranted, we will allow you sufficient time to appeal and obtain a decision from us before the reduction or termination takes effect.

• Concurrent Care Claims


If you request an extension of an ongoing course of treatment at least 24 hours prior to the expiration of the approved time period and this is also an urgent care claim, we will make a decision within 24 hours after we receive the claim.

Emergency services do not require prior authorization. However, if you are admitted to a facility, you or your family member must notify the Plan within 48 hours, or as soon as reasonably possible, or your claims may be denied.

You must obtain prior authorization from us for post-stabilization care you receive from non-Plan providers.

See Section 5(d), Emergency Services/Accidents for more information.

• Emergency services/accidents and post-stabilization care

If you request an extension of an ongoing course of treatment at least 24 hours prior to the expiration of the approved time period and this is also an urgent care claim, we will make a decision within 24 hours after we receive the claim.

• If your treatment needs to be extended

If you or your Plan provider do not obtain prior authorization from us for services or items that require prior authorization, we will not pay any amount for those services or items and you may be liable for the full price of those services or items. This also includes any residual amounts, such as deductibles, copayments or coinsurance that are not covered or not paid by any other insurance plan you use to pay for those services or items.

What happens when you do not follow the precertification rules

Under extraordinary circumstances, such as natural disasters, we may have to delay your services or we may be unable to provide them. In that case, we will make all reasonable efforts to provide you with the necessary care.

Circumstances beyond our control

If you have a pre-service claim and you do not agree with our prior approval decision, you may request a review in accord with the procedures detailed below.

If you have already received the service, supply, or treatment, then you have a post-service claim and must follow the entire disputed claims process detailed in Section 8.

If you disagree with our pre-service claim decision

Within 6 months of our initial decision, you may ask us in writing to reconsider our initial decision. Follow Step 1 of the disputed claims process detailed in Section 8 of this brochure.

In the case of a pre-service claim and subject to a request for additional information, we have 30 days from the date we receive your written request for reconsideration to do one of the following:

1. Precertify your hospital stay or, if applicable, arrange for the health care provider to give you the care or grant your request for prior approval for a service, drug, or supply.

2. Ask you or your provider for more information.

You or your provider must send the information so that we receive it within 60 days of our request. We will then decide within 30 more days.

If we do not receive the information within 60 days, we will decide within 30 days of the date the information was due. We will base our decision on the information we already have. We will write to you with our decision.

3. Write to you and maintain our denial.

• To reconsider a non-urgent care claim

In the case of an appeal of a pre-service urgent care claim, within 6 months of our initial decision, you may ask us in writing to reconsider our initial decision. Follow Step 1 of the disputed claims process detailed in Section 8 of this brochure.

• To reconsider an urgent care claim


Unless we request additional information, we will notify you of our decision within 72 hours after receipt of your reconsideration request. We will expedite the review process, which allows oral or written request for appeals and the exchange of information by telephone, electronic mail, facsimile, or other expeditious methods.

After we reconsider your pre-service claim, if you do not agree with our decision, you may ask OPM to review it by following Step 3 of the disputed claims process detailed in Section 8 of this brochure.

• To file an appeal with OPM

• Health Care FSA (HCFSA) – Reimburses you for eligible out-of-pocket health care expenses (such as copayments, deductibles, physician prescribed over-the-counter drugs and medications, vision and dental expenses, and much more) for you and your tax dependents, including adult children (through the end of the calendar year in which they turn 26).

• FSAFEDS offers paperless reimbursement for your HCFSA through a number of FEHB and FEDVIP plans. This means that when you or your provider files claims with your FEHB or FEDVIP plan, FSAFEDS will automatically reimburse your eligible out-of-pocket expenses based on the claim information it receives from your plan.

The Federal Flexible Spending Account Program – FSAFEDS


Section 4. Your Cost for Covered Services

This is what you will pay out-of-pocket for covered care:

Cost-sharing is the general term used to refer to your out-of-pocket costs (e.g., deductible, coinsurance, and copayments) for the covered care you receive.

Cost-sharing

A copayment is a fixed amount of money you pay to the provider, facility, pharmacy, etc., when you receive certain services. The amount of copayment will depend upon whether you are enrolled in the High, Standard or Basic Option, the type of provider, and the service or supply that you receive.

You pay a primary care provider copayment when you visit any primary care provider as described in Section 3, How You Get Care. You pay a specialist copayment when you receive care from a specialist as described in Section 3.

For example, under the High Option for diagnostic and treatment services as described in Section 5(a) you pay a $20 copayment when you receive diagnostic and treatment services from a primary care provider and a $30 copayment when you receive these services from a specialty care provider.

Under the Standard Option, you pay a $30 copayment when you receive diagnostic and treatment services from a primary care provider and a $40 copayment when you receive these services from a specialty care provider.

Under the Basic Option, you pay a $20 copayment when you receive diagnostic and treatment services from a primary care provider and a $50 copayment when you receive these services from a specialty care provider.

Copayments

A deductible is a fixed expense you must incur for certain covered services and supplies before we start paying benefits for them. Copayments do not count toward any deductible. • The High Option has no deductible. • The calendar year deductible is $150 per person under Standard Option. Under

a family enrollment, the deductible is considered satisfied and benefits are payable for all family members when the combined per person covered expenses applied to the calendar year deductible for family members reach $300 under Standard Option.

• The calendar year deductible is $500 per person under Basic Option. Under a family enrollment, the deductible is considered satisfied and benefits are payable for all family members when the combined per person covered expenses applied to the calendar year deductible for family members reach $1,000 under Basic Option.

Deductible

Coinsurance is the percentage of our allowance that you must pay for certain services you receive.

Example: In our Plan, you pay 50% of our allowance for infertility services.

Coinsurance

After your cost-sharing total is $4,000 per person up to $8,000 per family enrollment (High Option) or $5,500 per person up to $11,000 per family enrollment (Standard Option) or $6,500 per person up to $13,000 per family enrollment (Basic Option) in any calendar year, you do not have to pay any more for certain covered services that apply to your out-of-pocket maximum, as listed below. This includes any services required by group health plans to count toward the catastrophic protection out-of-pocket maximum by federal health care reform legislation (the Affordable Care Act and implementing regulations).

Your catastrophic protection out-of-pocket maximum


Example: Your plan has a $4,000 per person up to $8,000 per family maximum out-of-pocket limit. If you or one of your covered family members has out-of-pocket qualified medical expenses of $4,000 in a calendar year, any cost-sharing for qualified medical expenses for that individual will be covered fully by your health plan for the remainder of the calendar year. With a family enrollment, the out-of-pocket maximum will be satisfied once two or more family members have out-of-pocket qualified medical expenses of $8,000 in a calendar year, and any cost–sharing for qualified medical expenses for all enrolled family members will be covered fully by your health plan for the reminder of the calendar year.

However, cost-sharing for the following covered services do not count toward your catastrophic protection out-of-pocket maximum and you must continue to pay cost-sharing for these services: • Dental services • Travel benefit

Be sure to keep accurate records of your cost-sharing since you are responsible for informing us when you reach the maximum.

If you changed to this Plan during Open Season from a plan with a catastrophic protection benefit and the effective date of the change was after January 1, any expenses that would have applied to that plan’s catastrophic protection benefit during the prior year will be covered by your old plan if they are for care you received in January before your effective date of coverage in this Plan. If you have already met your old plan’s catastrophic protection benefit level in full, it will continue to apply until the effective date of your coverage in this Plan. If you have not met this expense level in full, your old plan will first apply your covered out-of-pocket expenses until the prior year’s catastrophic level is reached and then apply the catastrophic protection benefit to covered out-of-pocket expenses incurred from that point until the effective date of your coverage in this Plan. Your old plan will pay these covered expenses according to this year’s benefits; benefit changes are effective January 1.

Note: If you change options in this Plan during the year, we will credit the amount of covered expenses already accumulated toward the catastrophic out-of-pocket limit of your old option to the catastrophic protection limit of your new option.

Carryover

Facilities of the Department of Veterans Affairs, the Department of Defense and the Indian Health Service are entitled to seek reimbursement from us for certain services and supplies they provide to you or a family member. They may not seek more than their governing laws allow. You may be responsible to pay for certain services and charges. Contact the government facility directly for more information.

When Government facilities bill us


Section 5. High, Standard and Basic Option Benefits

High, Standard and Basic Option

See page 15 for how our benefits changed this year. See pages 99-101 for a benefits summary of each option. Make sure that you review the benefits that are available under the option in which you are enrolled. Section 5. High, Standard and Basic Option Benefits Overview ................................................................................................27 Section 5(a). Medical Services and Supplies Provided by Physicians and Other Health Care Professionals ............................29

Diagnostic and treatment services .....................................................................................................................................29 Telehealth services ............................................................................................................................................................30 Lab, X-ray and other diagnostic tests ................................................................................................................................30 Preventive care, adult ........................................................................................................................................................30 Preventive care, children ...................................................................................................................................................32 Maternity care ...................................................................................................................................................................34 Family planning ................................................................................................................................................................35 Infertility services .............................................................................................................................................................36 Allergy care .......................................................................................................................................................................37 Treatment therapies ...........................................................................................................................................................37 Physical and occupational therapies .................................................................................................................................38 Speech therapy ..................................................................................................................................................................39 Early childhood intervention services ...............................................................................................................................39 Hearing services (testing, treatment, and supplies) ...........................................................................................................40 Vision services (testing, treatment, and supplies) .............................................................................................................41 Foot care ............................................................................................................................................................................41 Orthopedic and prosthetic devices ....................................................................................................................................42 Durable medical equipment (DME) ..................................................................................................................................43 Home health services ........................................................................................................................................................45 Chiropractic Services ........................................................................................................................................................46 Alternative treatments .......................................................................................................................................................46 Educational classes and programs .....................................................................................................................................47

Section 5(b). Surgical and Anesthesia Services Provided by Physicians and Other Health Care Professionals ........................48 Surgical procedures ...........................................................................................................................................................48 Reconstructive surgery ......................................................................................................................................................50 Oral and maxillofacial surgery ..........................................................................................................................................51 Organ/tissue transplants ....................................................................................................................................................52 Anesthesia .........................................................................................................................................................................55

Section 5(c). Services Provided by a Hospital or Other Facility, and Ambulance Services .......................................................56 Inpatient hospital ...............................................................................................................................................................56 Outpatient hospital or ambulatory surgical center ............................................................................................................57 Skilled nursing care benefits .............................................................................................................................................58 Hospice care ......................................................................................................................................................................58 Ambulance ........................................................................................................................................................................59

Section 5(d). Emergency Services/Accidents .............................................................................................................................60 Emergency within our service area ...................................................................................................................................61 Emergency outside our service area ..................................................................................................................................62 Ambulance ........................................................................................................................................................................63

Section 5(e). Mental Health and Substance Use Disorder Benefits ............................................................................................64 Professional services .........................................................................................................................................................64 Inpatient hospital or other covered facility .......................................................................................................................65 Outpatient hospital or other covered facility .....................................................................................................................66

25 2020 Kaiser Foundation Health Plan of Colorado High, Standard and Basic Option Section 5


Section 5(f). Prescription Drug Benefits .....................................................................................................................................67 Covered medications and supplies ....................................................................................................................................68 Preventive Care medications .............................................................................................................................................71

Section 5(g). Dental Benefits ......................................................................................................................................................72 Accidental injury benefit ...................................................................................................................................................72

Section 5(h). Wellness and Other Special Features .....................................................................................................................73 Flexible benefits option .....................................................................................................................................................73 Options for care .................................................................................................................................................................73 Centers of Excellence ........................................................................................................................................................73 Services for the deaf, hard of hearing or speech impaired ................................................................................................73 Services from other Kaiser Permanente regions ...............................................................................................................74 Dependent out-of-area benefit ..........................................................................................................................................74 Travel benefit ....................................................................................................................................................................74 Rewards .............................................................................................................................................................................75

Summary of Benefits for the High Option of Kaiser Foundation Health Plan of Colorado - 2020 ...........................................99 Summary of Benefits for the Standard Option of Kaiser Foundation Health Plan of Colorado - 2020 ...................................100 Summary of Benefits for the Basic Option of Kaiser Foundation Health Plan of Colorado - 2020 .........................................101

26 2020 Kaiser Foundation Health Plan of Colorado High, Standard and Basic Option Section 5

Section 5. High, Standard and Basic Option Benefits Overview


This Plan offers a High, Standard and Basic Option. The benefit packages are described in Section 5. Make sure that you review the benefits that are available under the option in which you are enrolled.

The High, Standard and Basic Option Section 5 is divided into subsections. Please read Important things you should keep in mind at the beginning of the subsections. Also read the general exclusions in Section 6; they apply to the benefits in the following subsections. To obtain claim forms, claims filing advice, or more information about High, Standard and Basic Option benefits, contact us at 303-338-3800, toll-free 800-632-9700 in Denver/Boulder, 844-201-5824 in Northern Colorado, or 888-681-7878 in Southern Colorado, (TTY: 711) or on our website at kp.org/feds.

Since 1969, Kaiser Foundation Health Plan of Colorado has offered quality integrated health care to the FEHB Program. As a part of our commitment to keep pace with your health care needs, we are continually improving and enhancing your ability to manage your health online at kp.org.

High Option Our High Option provides the most comprehensive benefits. Our FEHB High Option includes:

• $20 primary care and $30 specialty care office visit copayments

• Inpatient hospital services covered at $500 per day up to $1,000 maximum per admission

• Outpatient hospital services covered at $200 per visit

• Key preventive services at no charge, including annual well-checks for adults and children, routine mammograms, pre/post-natal office visits and childhood immunizations

• $15 generic, $40 preferred brand-name, $60 non-preferred, and $100 specialty prescription drug copayments.

• A dependent out-of-area benefit, limited to 5 office visits, 5 diagnostic services, 5 therapy visits, and 5 prescription refills each calendar year, which provides coverage for dependents under the age of 26 who are temporarily outside any Kaiser Permanente service area.

Standard Option We also offer a Standard Option. With the Standard Option your copayments and coinsurance may be higher than for the High Option, but your premium is lower. Specific benefits of our FEHB Standard Option include:

• Calendar year deductible of $150 per person and $300 per family

• $30 primary care (no charge for children through age 17) and $40 specialty care office visit copayments

• Inpatient hospital services covered at $750 per admission after you have met your calendar year deductible

• Outpatient hospital services covered at $250 per visit after you have met your calendar year deductible




Basic Option We also offer a Basic Option. With the Basic Option your copayments and coinsurance may be higher than for the High and Standard Options, but your premium is lower. Specific benefits of our FEHB Basic Option include:

• Calendar year deductible of $500 per person and $1,000 per family

• $20 primary care and $50 specialty care office visit copayments

• Inpatient hospital services covered at 20% of our allowance after you have met your calendar year deductible

• Outpatient hospital services covered at 20% of our allowance after you have met your calendar year deductible

27 2020 Kaiser Foundation Health Plan of Colorado High, Standard and Basic Option Section 5 Overview





28 2020 Kaiser Foundation Health Plan of Colorado High, Standard and Basic Option Section 5 Overview

Section 5(a). Medical Services and Supplies Provided by Physicians and Other Health Care Professionals


Important things you should keep in mind about these benefits:

• Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and we cover them only when we determine they are medically necessary.

• Plan providers must provide or arrange your care.

• The Standard Option plan's calendar year deductible is $150 per person ($300 per family). The Basic Option's calendar year deductible is $500 per person ($1,000 per family). The calendar year deductible applies to some benefits in this Section. We added "after the deductible" when the calendar year deductible applies.

• There is no deductible for the High Option.

• Be sure to read Section 4, Your Cost for Covered Services, for valuable information about how cost-sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.

• Different copayments apply for primary care visits and specialty care visits. Please refer to Section 10, Definitions, to learn more about when your primary and specialty care copayments will apply.

Benefit Description You pay

Note: The Standard and Basic Option calendar year deductible applies to some benefits in this Section. We say "after the deductible" when it applies.

Diagnostic and treatment services High Option Standard Option Basic Option Professional services of physicians and other health care professionals • In a physician’s office • Office medical consultations • Second surgical opinion

$20 per primary care office visit $30 per specialty care office visit

Note: You pay $100 for drugs administered in connection with your care.

$30 per primary care office visit (nothing for children through age 17)

$40 per specialty care office visit

Note: You pay $150 after the deductible for drugs administered in connection with your care.

$20 per primary care office visit



Procedures received during an office visit Nothing after you pay the office visit copayment

Nothing after you pay the primary care copayment

Specialty care office copayment plus 10% of our allowance after the deductible

20% of our allowance after the deductible in addition to the office visit copayment

Professional services of physicians and other health care professionals • During a hospital stay • In a skilled nursing facility • In a rehabilitation facility

Nothing Nothing after the deductible

20% of our allowance after the deductible

Diagnostic and treatment services - continued on next page

29 2020 Kaiser Foundation Health Plan of Colorado High, Standard and Basic Option Section 5(a)



Diagnostic and treatment services (cont.)

High Option Standard Option Basic Option

• At home • Advance care planning







Telehealth services High Option Standard Option Basic Option Professional services of physicians and other health care professionals delivered through: • Interactive video • Telephone visits

Note: Visits may be limited by provider type and/or location.

Nothing Nothing Nothing

Lab, X-ray and other diagnostic tests High Option Standard Option Basic Option Tests, such as: • Blood tests • Urinalysis • Non-routine Pap tests • Pathology • Electrocardiogram


• X-rays • Non-routine mammograms • Ultrasound • EEG

Nothing Nothing 20% of our allowance after the deductible

• CT scans/MRI • PET scans • Nuclear medicine

$125 per procedure per body part

$150 per procedure per body part after the deductible


Preventive care, adult High Option Standard Option Basic Option One routine physical exam per calendar year, including • Alcohol use screening and behavioral

counseling interventions • Tobacco use screening and tobacco

cessation/E-cigarette interventions


Routine screenings, such as: • Total blood cholesterol • Depression • Diabetes


Preventive care, adult - continued on next page




Preventive care, adult (cont.) High Option Standard Option Basic Option • High blood pressure • HIV • Colorectal cancer screening, including

- Fecal occult blood test - Sigmoidoscopy screening - every five

years starting at age 50 - Colonoscopy screening – every ten years

starting at age 50 • Individual counseling on prevention and

reducing health risks


Routine Prostate Specific Antigen (PSA) test Nothing Nothing Nothing

Well woman care; based on current recommendations such as: • Cervical cancer screening (Pap smear) • Human papillomavirus (HPV) testing • Chlamydia/gonorrhea screening • Gonorrhea prophylactic medication to

protect newborns • Osteoporosis screening • Breast cancer screening • Counseling for sexually transmitted

infections • Counseling and screening for human

immune-deficiency virus • Contraceptive methods and counseling • Screening and counseling for interpersonal

and domestic violence • Perinatal depression: counseling and

interventions


Routine mammogram – covered for women Nothing Nothing Nothing

Adult immunizations endorsed by the Centers for Disease Control and Prevention (CDC): based on the Advisory Committee on Immunization Practices (ACIP) schedule


Preventive services required to be covered by group health plans at no cost share by federal health care reform legislation (the Affordable Care Act and implementing regulations).


Preventive care, adult - continued on next page




Preventive care, adult (cont.) High Option Standard Option Basic Option Notes: • You may pay cost-sharing for any procedure,

injection, diagnostic service, laboratory or X-ray service that is provided in conjunction with a routine physical exam and not considered a preventive service.

• A complete list of preventive care services recommended under the U.S. Preventive Services Task Force (USPSTF) is available online at: - www.uspreventiveservicestaskforce.org/

Page/Name/uspstf-a-and-b-recommendations/

- HHS: www.healthcare.gov/preventive-care-benefits/

- CDC: www.cdc.gov/vaccines/schedules/index.html

- Women’s preventive services: www.healthcare.gov/preventive-care-women/

- For additional information: https://healthfinder.gov/

Not covered: • Physical exams required for obtaining or

continuing employment or insurance, attending schools or camp, athletic exams, or travel.

• Immunizations, boosters, and medications for travel or work-related exposure.

All charges All charges All charges

Preventive care, children High Option Standard Option Basic Option Well-child visits, examinations, and immunizations as described in the Bright Future Guidelines provided by the American Academy of Pediatrics


Preventive services required to be covered by group health plans at no cost share by federal health care reform legislation (the Affordable Care Act and implementing regulations).


Preventive care, children - continued on next page




Preventive care, children (cont.) High Option Standard Option Basic Option Notes: • You may pay cost-sharing for any procedure,

injection, diagnostic service, laboratory or X-ray service that is provided in conjunction with a routine physical exam and not considered a preventive service.

• For a complete list of the American Academy of Pediatrics Bright Futures Guidelines go to https://brightfutures.aap.org/Pages/default.aspx

• A complete list of preventive care services recommended under the U.S. Preventive Services Task Force (USPSTF) is available online at: - www.uspreventiveservicestaskforce.org/

Page/Name/uspstf-a-and-b-recommendations/

- HHS: www.healthcare.gov/preventive-care-benefits/

- CDC: www.cdc.gov/vaccines/schedules/index.html

- For additional information: https://healthfinder.gov/

Note: Should you receive services for an illness, injury or condition during a preventive care examination, you may be charged the cost-share for professional services in a physician's office. See Section 5(a), Diagnostic and treatment services.

Not covered: • Physical exams and immunizations required

for:- Obtaining or continuing employment- Insurance or licensing- Participating in employee programs- Attending school, sports or camp- Court ordered parole or probation- Travel

• All other hearing testing, except as may be covered in Section 5(a), Diagnostic and treatment services and Section 5(a), Hearing services





Maternity care High Option Standard Option Basic Option Routine maternity (obstetrical) care, such as: • Prenatal care • Screening for gestational diabetes for

pregnant women • Postpartum care


• Office administered drugs Note: You pay $100 for drugs administered in connection with your care.



• Delivery Nothing Nothing 20% of our allowance after the deductible

Notes: • Routine maternity care is covered after

confirmation of pregnancy. • You do not need prior approval for

your vaginal delivery. See Section 3, You need prior Plan approval for certain services, for prior approval guidelines.

• You may remain in the hospital up to 48 hours after a vaginal delivery and 96 hours after a cesarean delivery. We will extend your inpatient stay if medically necessary.

• We cover routine nursery care of the newborn child during the covered portion of the mother’s maternity stay. We will cover other care of an infant who requires non-routine treatment only if we cover the infant under a Self Plus One or Self and Family enrollment. Surgical benefits, not maternity benefits, apply to circumcision.

• When a newborn requires definitive treatment during or after the mother's confinement, the newborn is considered a patient in his or her own right. If the newborn is eligible for coverage, regular medical or surgical benefits apply rather than maternity benefits.

• You pay cost-sharing for other services, including: - Diagnostic and treatment services for

illness or injury received during a non-routine maternity care visit as described in this section.

Maternity care - continued on next page




Maternity care (cont.) High Option Standard Option Basic Option - Lab, X-ray and other diagnostic tests

(including ultrasounds), durable medical equipment (including breastfeeding pumps) as described in this section.

- Surgical services (including circumcision of an infant if performed after the mother's discharge from the hospital) as described in Section 5(c) Outpatient hospital or ambulatory surgical center.

- Hospitalization (including room and board and delivery) as described in Section 5(c). Inpatient Hospital.

Family planning High Option Standard Option Basic Option A range of family planning services for women, limited to: • Female voluntary sterilization (See Section 5

(b), Surgical procedures) • Surgically implanted contraceptives • Injectable contraceptive drugs (such as Depo

Provera) • Intrauterine devices (IUDs) • Family planning counseling • Contraceptive counseling


Notes: • We cover oral contraceptive

drugs, diaphragms and cervical caps under Prescription drug benefits. See Section 5(f).

• For surgical costs associated with family planning, see Section 5(b), Surgical procedures.

• Male family planning services are covered in Primary and Specialty office visits. See Section 5(a), Diagnostic and treatment services.

Not covered: • Reversal of voluntary surgical sterilization • Genetic testing and counseling





Infertility services High Option Standard Option Basic Option Diagnosis and treatment of infertility, such as: • Artificial insemination:

-Intrauterine insemination (IUI) • Semen analysis • Hysterosalpingogram • Hormone evaluation

Notes: • Infertility is the inability of an individual to

conceive or produce conception during a period of 1 year if the female is age 35 or younger, or during a period of 6 months if the female is over the age of 35

• Infertility services are covered for individuals over the age of 18 who meet medically necessary criteria and are authorized by the Plan. See Section 3, You need prior Plan approval for certain services, for more information.

• Services are limited to 3 treatment cycles per pregnancy attempt with or without IUI.

50% of our allowance 50% of our allowance 50% of our allowance

Not covered:

These exclusions apply to fertile as well as infertile individuals or couples:• Assisted reproductive technology (ART)

procedures, including related services and supplies, such as:- In vitro fertilization (IVF)- Embryo transfer, gamete intra-fallopian

transfer (GIFT) and zygote intra-fallopian transfer (ZIFT)

• Sperm and eggs (whether from a member or from a donor) and services and supplies related to their procurement and storage, including freezing

• Ovum transplants• Fertility drugs• Infertility services when either member of

the family has been voluntarily, surgically sterilized

• Services to reverse voluntary, surgically induced infertility

• Intravaginal insemination (IVI)• Intra-cervical insemination (ICI)





Allergy care High Option Standard Option Basic Option • Testing and treatment $20 per primary care

office visit









• Injections $20 per office visit

Note: You pay $100 for drugs administered in connection with your care (other than allergy injections & serum).

$30 per office visit

Note: You pay $150 after the deductible for drugs administered in connection with your care (other than allergy injections & serum).


Note: You pay $200 after the deductible for drugs administered in connection with your care (other than allergy injections & serum).

• Serum Nothing Nothing Nothing

Not covered:• Provocative food testing• Sublingual allergy desensitization


Treatment therapies High Option Standard Option Basic Option Chemotherapy

Note: High dose chemotherapy in association with autologous bone marrow transplants is limited to those transplants listed under Section 5(b), Organ/Tissue transplants.







• Radiation therapy • Respiratory and inhalation therapy • Dialysis – hemodialysis and peritoneal

dialysis

Note: We waive office visit charges for dialysis if you enroll in Medicare Part B and assign your Medicare benefits to us.







Cardiac rehabilitation following a qualifying event/condition

$40 per office visit 10% of our allowance after the deductible


Treatment therapies - continued on next page 37 2020 Kaiser Foundation Health Plan of Colorado High, Standard and Basic Option Section 5(a)



Treatment therapies (cont.) High Option Standard Option Basic Option Ultraviolet light treatments Nothing Nothing Nothing

Intravenous (IV)/Infusion Therapy $30 per office visit






Notes: • IV, antibiotic therapy and growth hormone

require our prior approval and are covered under the prescription drug benefit. See Section 3, You need prior Plan approval for certain services and Section 5(f), Prescription Drug Benefits.

• See Section 5(e) Professional services, for coverage of Applied Behavior Analysis (ABA).

Not covered:• Chemotherapy supported by a bone marrow

transplant or with stem cell support, for any diagnosis not listed as covered under Section 5(b), Organ/Tissue transplants.


Physical and occupational therapies High Option Standard Option Basic Option We cover up to 20 outpatient rehabilitative and up to 20 outpatient habilitative visits per year of each therapy, except we cover rehabilitative and habilitative services with no visit limits with a diagnosis of autism spectrum disorders (ASD). Coverage for rehabilitative and habilitative services includes: • Physical therapy by qualified physical

therapists to attain or restore bodily function when you have a total or partial loss of bodily function due to illness or injury

• Occupational therapy by occupational therapists to assist you in attaining or resuming self-care and improved functioning in other activities of daily life when you have a total or partial loss of bodily function due to illness or injury

$20 per office visit $30 per office visit $20 per office visit

We cover up to 20 pulmonary rehabilitation visits per year.


Not covered:• Long-term therapy, not including treatment

of autism spectrum disorders


Physical and occupational therapies - continued on next page 38 2020 Kaiser Foundation Health Plan of Colorado High, Standard and Basic Option Section 5(a)



Physical and occupational therapies (cont.)


• Exercise programs• Maintenance therapy, not including

treatment of autism spectrum disorders • Vocational rehabilitation programs• Therapies done primarily for educational

purposes• Services provided by local, state, and federal

government agencies, including schools


Speech therapy High Option Standard Option Basic Option We cover up to 20 outpatient habilitative and up to 20 outpatient rehabilitative visits per year, except we cover habilitative and rehabilitative services with no visit limits with a diagnosis of autism spectrum disorders (ASD) or treatment of cleft lip or cleft palate.


Not covered:• Therapies done primarily for educational

purposes• Therapy for tongue thrust in the absence of

swallowing problems• Voice therapy for occupation or performing

arts• Services provided by local, state, and federal

government agencies, including schools


Early childhood intervention services High Option Standard Option Basic Option Through age two (2), early intervention services (EIS) are covered for children with significant delays in development or a diagnosed physical or mental condition that has a high probability of resulting in significant delays in development as defined by Colorado state law.

Limitations: The amount of coverage required by state law does not apply to: • Rehabilitation or therapeutic services that are

necessary as the result of an acute medical condition

• Services provided to a child who is not participating in an early intervention program for infants and toddlers under Part C of the federal “Individuals with Disabilities Education Act” and that are not provided pursuant to an Individualized Family Service Plan

All charges in excess of the amount of coverage required by state law.



Early childhood intervention services - continued on next page 39 2020 Kaiser Foundation Health Plan of Colorado High, Standard and Basic Option Section 5(a)



Early childhood intervention services (cont.)


Not covered:• Respite care• Non-emergency medical transportation• Service coordination, as defined by law• Assistive technology, not to include durable

medical equipment that is otherwise covered


Hearing services (testing, treatment, and supplies)


• Hearing aids for children under age 18 are covered not more frequently than every 5 years, except when alterations to the existing hearing aid cannot adequately meet the needs of the child. Services and supplies include, but are not limited to, the initial hearing assessment, fitting, adjustments, and auditory training that is provided according to accepted professional standards.

Notes:

For coverage of: • Hearing screenings, see Section 5(a),

Preventive care, children and, for any other hearing testing, see Section 5(a), Diagnostic and treatment services.

• Audible prescription reading and speech generating devices, see Section 5(a), Durable medical equipment.

$20 per office visit 10% of our allowance after the deductible


Not covered:• All other hearing testing, except as may be

covered in Section 5(a), Diagnostic and treatment services and Section 5(a), Preventive care, children

• Hearing aids, including testing and examinations for them, for all persons age 18 and over





Vision services (testing, treatment, and supplies)


Diagnosis and treatment of diseases of the eye $20 per primary care office visit









Routine eye exam with a Plan optometrist or ophthalmologist to determine the need for vision correction and provide a prescription for eyeglasses










Not covered:• Eyeglass lenses or frames • Contact lenses, examinations for contact

lenses or the fitting of contact lenses • Eye surgery solely for the purpose of

correcting refractive defects of the eye• Vision therapy, including orthoptics, visual

training and eye exercises


Foot care High Option Standard Option Basic Option Routine foot care when you are under active treatment for a metabolic or peripheral vascular disease, such as diabetes.










Foot care - continued on next page




Foot care (cont.) High Option Standard Option Basic Option Not covered:• Cutting, trimming or removal of corns,

calluses, or the free edge of toenails and similar routine treatment of conditions of the foot, except as stated above

• Treatment of weak, strained or flat feet or bunions or spurs; and of any instability, imbalance or subluxation of the foot (unless the treatment is by open cutting surgery)


Orthopedic and prosthetic devices High Option Standard Option Basic Option External prosthetic and orthotic devices, such as: • Artificial limbs • Externally worn breast prostheses and

surgical bras following a mastectomy, including necessary replacements

• Artificial eyes • Prosthetic sleeve or sock • Corrective orthopedic appliances for non-

dental treatment of temporomandibular joint (TMJ) pain dysfunction syndrome


Internal prosthetic devices, such as: • Artificial joints • Pacemakers • Cochlear implants • Surgically implanted breast implants

following mastectomy

Note: See Section 5(b), Surgical procedures, for coverage of the surgery to insert the device and Section 5(c) for inpatient hospital benefits.


Orthopedic and prosthetic devices - continued on next page




Orthopedic and prosthetic devices (cont.)


Notes: • Orthopedic and prosthetic equipment or

services must be prescribed by a Plan physician; obtained through sources designated by the Plan; consistent with our Plan DME formulary guidelines; and primarily and customarily used to serve a medical or therapeutic purpose in the treatment of an illness or injury.

• We cover only those standard items that are adequate to meet the medical needs of the member.

• For coverage of hearing aids, see Section 5(a), Hearing services.

Not covered:• Orthopedic and prosthetic devices and

corrective shoes, except as described above • Foot orthotics and podiatric use devices,

such as arch supports, heel pads and heel cups

• Comfort, convenience, or luxury equipment or features

• Prosthetic devices, equipment, and supplies related to treatment of sexual dysfunction

• Dental prostheses, devices, and appliances; except, we will provide medically necessary orthodontic and prosthodontic treatment for cleft lip or cleft palate for the repair of congenital anomalies, unless these services are covered under a dental insurance policy

• Spare or alternate use devices• Repairs, adjustments, or replacements due to

misuse, theft, or loss


Durable medical equipment (DME) High Option Standard Option Basic Option We cover rental or purchase of durable medical equipment, at our option. Covered items include: • Oxygen • Oxygen dispensing equipment • Insulin pumps • Infant apnea monitors


• Dialysis equipment • Hospital beds


Durable medical equipment (DME) - continued on next page 43 2020 Kaiser Foundation Health Plan of Colorado High, Standard and Basic Option Section 5(a)



Durable medical equipment (DME) (cont.)


• Wheelchairs, including motorized wheelchairs when medically necessary

• Crutches • Walkers • Speech generating devices • Blood glucose monitors • Commodes • Respirators


• Breastfeeding pumps, including any equipment that is required for pump functionality


Notes: • Durable medical equipment (DME) is

equipment that is prescribed by a Plan physician; obtained through sources designated by the Plan; consistent with our Plan DME formulary guidelines; intended for repeated use; primarily and customarily used to serve a medical or therapeutic purpose in the treatment of an illness or injury; designed for prolonged use; and appropriate for use in the home.

• We cover only those standard items that are adequate to meet the medical needs of the member.

• We may require you to return the equipment to us, or pay us the fair market price of the equipment, when it is no longer prescribed.

• When outside the service area, you must obtain your oxygen supplies and services from our designated vendor.

Not covered: • Audible prescription reading devices• Comfort, convenience, or luxury equipment

or features• Non-medical items such as sauna baths or

elevators• Exercise and hygiene equipment• Electronic monitors of the heart, lungs or

other bodily functions, except for infant apnea monitors

• Devices to perform medical testing of bodily fluids, excretions, or substances


Durable medical equipment (DME) - continued on next page




Durable medical equipment (DME) (cont.)


• Devices, equipment, and supplies related to the treatment of sexual dysfunction disorders

• Modifications to the home or vehicle• Dental appliances• More than one piece of durable medical

equipment serving essentially the same function

• Spare or alternate use equipment• Disposable supplies• Replacement batteries• Repairs, adjustments, or replacements due

to misuse, theft, or loss


Home health services High Option Standard Option Basic Option • Home health care ordered by a Plan

physician and provided by a registered nurse (R.N.), licensed practical nurse (L.P.N.), licensed vocational nurse (L.V.N.), home health aide, physical or occupational therapist, and speech and language pathologist.

• Services include oxygen therapy, intravenous therapy, and medications.

Notes: • We only provide these services in the Plan's

service areas. • The services are covered only if you are

homebound and a Plan physician determines that it is feasible to maintain effective supervision and control of your care in your home.

• See Section 3, You need prior Plan approval for certain services.

Nothing 10% of our allowance after the deductible


Not covered:• Nursing care requested by, or for the

convenience of, the patient or the patient's family

• Home care primarily for personal assistance that does not include a medical component and is not diagnostic, therapeutic, or rehabilitative

• Custodial care• Private duty nursing• Personal care and hygiene items


Home health services - continued on next page 45 2020 Kaiser Foundation Health Plan of Colorado High, Standard and Basic Option Section 5(a)



Home health services (cont.) High Option Standard Option Basic Option • Homemaker services • Care that a Plan provider determines may be

appropriately provided in a Plan facility, hospital, skilled nursing facility, or other facility we designate and we provide, or offer to provide, that care in one of these facilities


Chiropractic Services High Option Standard Option Basic Option Up to 20 visits per calendar year limited to: • Diagnosis and treatment of

neuromusculoskeletal disorders • Laboratory tests and plain film X-rays

associated with diagnosis and treatment


Notes: • You may only self-refer to a participating

provider. The participating provider must provide, arrange or prescribe your care.

• For a list of participating providers call Member Services at 303-338-3800 or toll-free 800-632-9700 (Denver/Boulder), 844-201-5824(Northern Colorado), or 888-681-7878 (Southern Colorado), (TTY: 711).

Not covered:• Hypnotherapy, behavior training, sleep

therapy and weight programs• Thermography• Any radiological exam other than plain file

studies such as magnetic resonance imaging, CT scans, bone scans, nuclear radiology

• Treatment for non-neuromusculoskeletal disorders, including adjunctive therapy

• Chiropractic appliances, except as covered in Section 5(a), Durable medical equipment and Prosthetics and orthotic devices


Alternative treatments High Option Standard Option Basic Option Not covered, including acupuncture All charges All charges All charges




Educational classes and programs High Option Standard Option Basic Option Health education classes, including: • Stress reduction • Weight control

Charges vary Charges vary Charges vary

• Tobacco cessation/E-cigarettes programs, including individual, group and telephone counseling


Health education services and education in the appropriate use of Health Plan services







Notes: • For information on the cost and classes near

you, please call Member Services at 303-338-3800 or toll-free 800-632-9700 (Denver/Boulder), 844-201-5824 (Northern Colorado), or 888-681-7878 (Southern Colorado), (TTY: 711).

• You pay nothing for over-the-counter (OTC) and prescription drugs approved by the FDA to treat tobacco/E-cigarette dependence. See Section 5(f), Prescription Drug Benefits, for important information about coverage of tobacco/e-cigarette cessation and other drugs.

• You can also participate in programs that are available through Kaiser Permanente as non-FEHB benefits. These programs may require that you pay a fee. See the end of Section 5, Non-FEHB Benefits Available to Plan Members.


Section 5(b). Surgical and Anesthesia Services Provided by Physicians and Other Health Care Professionals




• Plan providers must provide or arrange your care. Consult with your provider to determine what is appropriate for you. Services may be covered provided that established Plan criteria are met.

• The Standard Option plan’s calendar year deductible is $150 per person ($300 per family). The Basic Option's calendar year deductible is $500 per person ($1,000 per family). The calendar year deductible applies to some benefits in this Section. We added "after the deductible" when the calendar year deductible applies.



• The services listed below are for the charges billed by a physician or other health care professional for your surgical care. See Section 5(a) for charges associated with office visits and Section 5(c) for charges associated with the facility (i.e. hospital, surgical center, etc.).



Surgical procedures High Option Standard Option Basic Option A comprehensive range of services, such as: • Operative procedures • Treatment of fractures, including casting • Normal pre- and post-operative care by the

surgeon • Correction of amblyopia and strabismus • Endoscopy procedures • Biopsy procedures • Removal of tumors and cysts • Surgical treatment for gender reassignment

to treat gender dysphoria • Correction of congenital anomalies (see

Reconstructive surgery) • Epidural steroid injections

Nothing Nothing, except 10% of our allowance after the deductible for procedures in a specialist's office


• Surgical treatment of morbid obesity (bariatric surgery). You must: - be 18 years of age or older at the time of

application; and



Surgical procedures - continued on next page

48 2020 Kaiser Foundation Health Plan of Colorado High, Standard and Basic Option Section 5(b)



Surgical procedures (cont.) High Option Standard Option Basic Option - have a Body Mass Index (BMI) of 40 or

greater, with or without the presence of co-morbidities; or have a BMI of 35 to 39.9 and diabetes; or have a BMI of 35 to 39.9, without diabetes, when any one of the following life-threatening co-morbidities are present and if they have failed standard medical therapy: obesity-related pulmonary or cardiovascular disease (lung or heart disease); uncontrolled hypertension (uncontrolled high blood pressure); severe osteoarthritis (swelling of a weight bearing joint); pseudotumor cerebri (high pressure in fluid around the brain); and severe dyslipidemia (disorder of fats and cholesterol in the blood)

Notes: • You will need to meet the above

qualifications before your Plan provider will refer you to our bariatric surgery program. This program may refer you to other Plan providers to determine if you meet the additional criteria necessary for bariatric surgery, including nutritional, psychological, medical and social readiness for surgery. Final approval for surgical treatment will be required from the Colorado Permanente Medical Group’s designated physician.

• See Section 3, You need prior Plan approval for certain services, for more information.



• Insertion of internal prosthetic devices. See Section 5(a), Orthopedic and prosthetic devices, for device coverage information

• Male voluntary sterilization (e.g., vasectomy)

• Treatment of burns

Notes: • Generally, we pay for internal prostheses

(devices) according to where the procedure is done. For example, we pay Hospital benefits for a pacemaker and Surgery benefits for insertion of the pacemaker.



• Female sterilization, including anesthesia and confirmation testing following tubal occlusion


Surgical procedures - continued on next page




Surgical procedures (cont.) High Option Standard Option Basic Option Not covered: • Reversal of voluntary sterilization • Implants or devices related to the treatment

of sexual dysfunction• Services for the promotion, prevention, or

other treatment of hair loss or hair growth• Cosmetic surgery - any surgical procedure

(or any portion of a procedure) performed primarily to improve physical appearance through change in bodily form.

• Facial feminization and breast augmentation for the treatment of gender dysphoria


Reconstructive surgery High Option Standard Option Basic Option • Surgery to correct a functional defect • Surgery to correct a condition caused by

injury or illness if: - the condition produced a major effect on

the member’s appearance; and - the condition can reasonably be expected

to be corrected by such surgery. • Surgery to correct a condition that existed at

or from birth and is a significant deviation from the common form or norm. Examples of congenital anomalies are protruding ear deformities; cleft lip; cleft palate; birthmarks; and webbed fingers and toes.

• Surgery for treatment of a form of congenital hemangioma known as port wine stains.

• All stages of breast reconstruction surgery following a mastectomy, such as: - surgery and reconstruction on the other

breast to produce a symmetrical appearance;

- treatment of any physical complications, such as lymphedemas;

- breast prostheses and surgical bras and replacements (see Prosthetic devices).

Note: If you need a mastectomy, you may choose to have the procedure performed on an inpatient basis and remain in the hospital up to 48 hours after the procedure.



Reconstructive surgery - continued on next page




Reconstructive surgery (cont.) High Option Standard Option Basic Option Not covered: • Cosmetic surgery – any surgical procedure

(or any portion of a procedure) performed primarily to improve physical appearance through change in bodily form, except repair of accidental injury.


Oral and maxillofacial surgery High Option Standard Option Basic Option Oral surgical procedures, limited to: • Reduction of fractures of the jaws or facial

bones • Surgical correction of cleft lip, cleft palate,

or severe functional malocclusion • Removal of stones from salivary ducts • Excision of leukoplakia or malignancies • Excision of cysts and incision of abscesses

when done as independent procedures • Medical and surgical treatment of

temporomandibular joint (TMJ) disorder (non-dental); and

• Other surgical procedures that do not involve the teeth or their supporting structures

Nothing

Note: You pay $100 for drugs administered in an office in connection with your care.

Nothing, except 10% of our allowance after the deductible for procedures in a specialist's office

Note: You pay $150 after the deductible for drugs administered in an office in connection with your care.


Note: You pay $200 after the deductible for drugs administered in an office in connection with your care.

Not covered:• Oral implants and transplants• Procedures that involve the teeth or their

supporting structures (such as the periodontal membrane, gingiva, and alveolar bone)

• Shortening of the mandible or maxillae for cosmetic purposes

• Correction of any malocclusion not listed above

• Dental care involved in treatment of the temporomandibular joint (TMJ) pain dysfunction syndrome

• Dental services associated with medical treatment such as radiation treatment (See Section 5(g))





Organ/tissue transplants High Option Standard Option Basic Option These solid organ transplants are subject to medical necessity and experimental/investigational review by the Plan. Refer to Section 3, How You Get Care for prior authorization procedures. Solid organ tissue transplants are limited to: • Autologous pancreas islet cell transplant (as

an adjunct to total or near total pancreatomy) only for patients with chronic pancreatitis

• Cornea • Heart • Heart/lung • Intestinal transplants

- Isolated small intestine - Small intestine with the liver - Small intestine with multiple organs, such

as the liver, stomach, and pancreas • Kidney • Kidney/pancreas • Liver • Lung: single/bilateral/lobar • Pancreas



Blood or marrow stem cell transplants

The Plan extends coverage for the diagnoses as indicated below: • Allogeneic transplants for:

- Acute lymphocytic or non-lymphocytic - (i.e., myelogenous) leukemia - Acute myeloid leukemia - Advanced Hodgkin’s lymphoma with

recurrence (relapsed) - Advanced Myeloproliferative Disorders

(MPDs) - Advanced non-Hodgkin’s lymphoma with

recurrence (relapsed) - Amyloidosis - Chronic lymphocytic leukemia/small

lymphocytic lymphoma (CLL/SLL) - Hemoglobinopathy - Marrow Failure and Related Disorders

(i.e. Fanconi's, Paroxysmal Nocturnal Hemoglobinuria, Pure Red Cell Aplasia)



Organ/tissue transplants - continued on next page




Organ/tissue transplants (cont.) High Option Standard Option Basic Option - Myelodysplasia/Myelodysplastic

syndromes - Paroxysmal Nocturnal Hemoglobinuria - Phagocytic/Hemophagocytic deficiency

diseases (e.g., Wiskott-Aldrich syndrome) - Severe combined immunodeficiency - Severe or very severe aplastic anemia - Sickle cell anemia - X-linked lymphoproliferative syndrome

• Autologous transplants for: - Acute lymphocytic or nonlymphocytic

(i.e., myelogenous) leukemia - Advanced Hodgkin’s lymphoma with

recurrence (relapsed) - Advanced non-Hodgkin’s lymphoma with

recurrence (relapsed) - Amyloidosis - Epithelial ovarian cancer - Multiple myeloma - Neuroblastoma - Testicular, mediastinal, retroperitoneal,

and ovarian germ cell tumors



Limited benefits - The following autologous blood or bone marrow stem cell transplants may be provided in a National Cancer Institute (NCI) or National Institutes of Health (NIH)-approved clinical trial at a Plan-designated Center of Excellence. These limited benefits are not subject to medical necessity. • Advanced childhood kidney cancers • Advanced Ewing sarcoma • Aggressive non-Hodgkin's lymphomas • Breast cancer • Childhood rhabdomyosarcoma • Epithelial ovarian cancer • Mantle Cell (Non-Hodgkin's lymphoma)



Mini-transplants performed in a Clinical Trial Setting (non-myeloblative, reduced intensity conditioning or RIC) • Allogeneic transplants for:

- Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia

- Acute myeloid leukemia



Organ/tissue transplants - continued on next page 53 2020 Kaiser Foundation Health Plan of Colorado High, Standard and Basic Option Section 5(b)



Organ/tissue transplants (cont.) High Option Standard Option Basic Option - Advanced Hodgkin’s lymphoma with

recurrence (relapsed) - Advanced Myeloproliferative Disorders

(MPDs) - Advanced non-Hodgkin’s lymphoma with

recurrence (relapsed) - Amyloidosis - Chronic lymphocytic leukemia/small

lymphocytic lymphoma (CLL/SLL) - Chronic myelogenous leukemia - Hemoglobinopathy - Marrow Failure and Related Disorders

(i.e. Fanconi's, Paroxysmal Nocturnal Hemoglobinuria, Pure Red Cell Aplasia)

- Myelodysplasia/Myelodysplastic syndromes

- Paroxysmal Nocturnal Hemoglobinuria - Severe combined immunodeficiency - Severe or very severe aplastic anemia

• Autologous transplants for: - Acute lymphocytic or nonlymphocytic

(i.e., myelogenous) leukemia - Advanced Hodgkin’s lymphoma with

recurrence (relapsed) - Advanced non-Hodgkin’s lymphoma with

recurrence (relapsed) - Amyloidosis - Neuroblastoma



Tandem transplants: Subject to medical necessity • Autologous tandem transplants for:

- AL Amyloidosis - Multiple myeloma (de novo and treated) - Recurrent germ cell tumors (including

testicular cancer)



Organ/tissue transplants - continued on next page




Organ/tissue transplants (cont.) High Option Standard Option Basic Option Notes: • We cover related medical and hospital

expenses of the donor when we cover the recipient.

• We cover donor screening tests for potential donors for solid organ transplants. We cover human leukocyte antigen (HLA) typing for potential donors for a bone marrow/stem cell transplant only for parents, children and siblings of the recipient.

• We cover computerized national and international search expenses for prospective unrelated bone marrow/stem cell transplant donors conducted through the National Marrow Donor Program, and the testing of blood relatives of the recipient.

• Please refer to Section 5(h), Wellness and Other Special Features, for information on our Centers of Excellence.

Not covered: • Donor screening tests and donor search

expenses, except those listed above• Implants of non-human artificial organs• Transplants not listed as covered


Anesthesia High Option Standard Option Basic Option Professional services provided in • Hospital (inpatient and outpatient) • Ambulatory surgical center • Skilled nursing facility • Office



Not covered:• Anesthesia for dental services, other than

general anesthesia for a dependent child with physical, mental, or behavior problems



Section 5(c). Services Provided by a Hospital or Other Facility, and Ambulance Services




• Plan providers must provide or arrange your care and you must be hospitalized in a Plan facility.

• The Standard Option plan’s calendar year deductible is $150 per person ($300 per family). The Basic Option plan’s calendar year deductible is $500 per person ($1,000 per family). The calendar year deductible applies to some benefits in this Section. We added "after the deductible" when the calendar year deductible applies.



• The amounts listed below are for the charges billed by the facility (i.e., hospital or surgical center) or ambulance service for your surgery or care. Any costs associated with the professional charge (i.e., physicians, etc.) are covered in Sections 5(a) or (b).



Inpatient hospital High Option Standard Option Basic Option Room and board, such as • Ward, semiprivate, or intensive care

accommodations • General nursing care • Meals and special diets

Note: If you want a private room when it is not medically necessary, you pay the additional charge above the semiprivate room rate.

$500 per day up to $1,000 maximum per admission, except nothing for maternity care delivery

$750 per admission after the deductible, except nothing (no deductible) for maternity care delivery


Other hospital services and supplies, such as: • Operating, recovery, maternity, and other

treatment rooms • Prescribed drugs and medications • Diagnostic laboratory tests and X-rays • Blood and blood products • Dressings, splints, casts, and sterile tray

services • Medical supplies and equipment, including

oxygen • Anesthetics, including nurse anesthetist

services


Inpatient hospital - continued on next page

56 2020 Kaiser Foundation Health Plan of Colorado High, Standard and Basic Option Section 5(c)



Inpatient hospital (cont.) High Option Standard Option Basic Option Note: You may receive covered hospital services for certain dental procedures if a Plan physician determines you need to be hospitalized for reasons unrelated to the dental procedure. The need for anesthesia, by itself, is not such a condition.

We cover general anesthesia for dental services for a dependent child with physical, mental, or behavior problems.


Not covered: • Custodial care and care in an intermediate

care facility • Non-covered facilities, such as nursing

homes • Personal comfort items, such as telephone,

television, barber services, and guest meals and beds

• Private nursing care, except when medically necessary

• Inpatient dental procedures


Rehabilitation facility High Option Standard Option Basic Option Up to 60 days per condition of multidisciplinary rehabilitation services program in a designated rehabilitation facility

Nothing $750 per admission after the deductible


Outpatient hospital or ambulatory surgical center


• Operating, recovery, and other treatment rooms

• Prescribed drugs and medications • Lab, X-ray and other diagnostic tests • Blood and blood products • Pre-surgical testing • Dressings, casts and sterile tray services • Medical supplies and equipment, including

oxygen • Anesthetics and anesthesia service

$200 per visit $250 after the deductible


Outpatient hospital or ambulatory surgical center - continued on next page




Outpatient hospital or ambulatory surgical center (cont.)


Notes: • You may receive covered outpatient hospital

services for certain dental procedures if a Plan physician determines you need outpatient hospital services for reasons unrelated to the dental procedure. The need for anesthesia, by itself, is not such a condition. See Section 5(g) for details of your dental benefits.

• We cover general anesthesia for dental services for a dependent child with physical, mental, or behavior problems.

Skilled nursing care benefits High Option Standard Option Basic Option Up to 100 days per calendar year when you need full-time skilled nursing care.

All necessary services are covered, including: • Room and board • General nursing care • Medical social services • Prescribed drugs, biologicals, supplies, and

equipment, including oxygen, ordinarily provided or arranged by the skilled nursing facility

Nothing Nothing after the deductible


Not covered: • Custodial care and care in an intermediate

care facility• Personal comfort items, such as telephone,

television, barber services, and guest meals and beds


Hospice care High Option Standard Option Basic Option Supportive and palliative care for a terminally ill member: • You must reside in the service area. • Services are provided:

- in the home, when a Plan physician determines that it is feasible to maintain effective supervision and control of your care in your home, or

- in a Plan approved hospice facility if approved by the hospice interdisciplinary team.

Nothing Nothing for home-based hospice services

10% of our allowance after the deductible for inpatient admission

Nothing for home-based hospice services


Hospice care - continued on next page




Hospice care (cont.) High Option Standard Option Basic Option Services include inpatient care, outpatient care, and family counseling. A Plan physician must certify that you have a terminal illness, with a life expectancy of approximately six months or less.

Nothing Nothing for home-based hospice services


Nothing for home-based hospice services


Special Services Program

Hospice-eligible members who have not yet elected hospice care are eligible to receive home visits by Plan special service hospice providers.


Note: Hospice is a program for caring for the terminally ill patient that emphasizes supportive services, such as home care and pain and symptom control, rather than curative care. A person who is terminally ill may elect to receive hospice benefits. These palliative and supportive services include nursing care, medical social services, therapy services for purposes of safety and symptom control, physician services, palliative drugs in accord with our drug formulary guidelines, and short-term inpatient care for pain control and acute and chronic symptom management. We also provide inpatient respite care, counseling and bereavement services. If you make a hospice election, you are not entitled to receive other health care services that are related to the terminal illness. If you have made a hospice election, you may revoke that election at any time, and your standard health benefits will be covered.

Not covered: • Independent nursing (private duty nursing) • Homemaker services


Ambulance High Option Standard Option Basic Option • Local licensed ambulance service when

medically necessary

Note: See Section 5(d) for emergency services.

$150 per trip $200 per trip 20% of our allowance up to $500 per trip

Not covered: • Transportation by car, taxi, bus, gurney van,

wheelchair van, and any other type of transportation (other than a licensed ambulance), even if it is the only way to travel to a Plan Provider



Section 5(d). Emergency Services/Accidents




• The Standard Option plan’s calendar year deductible is $150 per person ($300 per family). The Basic Option plan’s calendar year deductible is $500 per person ($1,000 per family). The calendar year deductible applies to some benefits in this Section. We added "after the deductible" when the calendar year deductible applies.


• If you receive special procedures (MRIs, CAT scans, PET scans and nuclear medicine) while in the hospital emergency room, you pay the amount specified in Section 5(a). Your copayment for the special procedures performed in a hospital emergency room will be waived if you are admitted to the hospital as an inpatient.


What is a medical emergency?

A medical emergency is the sudden and unexpected onset of a condition or an injury that you believe endangers your life or could result in serious injury or disability, and requires immediate medical or surgical care. Some problems are emergencies because, if not treated promptly, they might become more serious; examples include deep cuts and broken bones. Others are emergencies because they are potentially life-threatening, such as heart attacks, strokes, poisonings, gunshot wounds, or sudden inability to breathe. There are many other acute conditions that we may determine are medical emergencies – what they all have in common is the need for quick action.

What to do in case of emergency:

You are covered for medical emergencies anywhere in the world. In a life-threatening emergency, call 911 or go to the nearest emergency room. If you call 911, when the operator answers, stay on the phone and answer all questions.

Emergencies within our service area:

If you think you have a life- or limb-threatening emergency, call 911 or go to the nearest emergency room.

When you are sick or injured, you may have an urgent care need. An urgent care need is one that requires prompt medical attention, but is not a medical emergency. If you think you may need urgent care, call the appropriate appointment or advice nurse number at a Plan facility. A Plan provider will determine if care can be provided at home or in an urgent care center. In Denver/Boulder, call 303-338-4545 or toll-free 800-218-1059 (TTY: 711) for advice, 24 hours a day, seven days a week. In Northern and Southern Colorado call 800-218-1059 (TTY: 711) for advice, 24 hours a day, seven days a week. For an appointment, call your PCP’s office. Visit kp.org/feds to find locations and hours of accessibility for a designated Plan urgent care center. Urgent care received at a non-Plan facility in your Service Area is not covered. You will be responsible for payment for any treatment received at a non-Plan urgent care facility in your Service Area.

Emergencies outside our service area:

We cover emergency situations, such as myocardial infarction, appendicitis or premature delivery, outside the service area. Note: Emergency services are limited to those services required before your medical condition permits your travel or transfer to care in our Plan. Continuing or follow-up care from non-Plan providers is not covered.

60 2020 Kaiser Foundation Health Plan of Colorado High, Standard and Basic Option Section 5(d)


When you are sick or injured, you may have an urgent care need. An urgent care need is one that requires prompt medical attention, but is not a medical emergency. If you think you may need urgent care, call the appropriate appointment or advice nurse number at a Plan facility. Please refer to the Guidebook for advice nurse and Plan facility telephone numbers. If you are temporarily outside the service area and have an urgent care need due to unforeseen illness or injury, we cover the medically necessary services and supplies you receive from a non-Plan provider if we find that the services and supplies were necessary to prevent serious deterioration of your health and they could not be delayed until you returned to the service area.

You may obtain emergency and urgent care services from Kaiser Permanente medical facilities and providers when you are in the service area of another Kaiser Permanente plan. The facilities are listed in the local telephone book under Kaiser Permanente. These numbers are available 24 hours a day, seven days a week. You may also obtain information about the location of facilities by calling Member Services at 303-338-3800 or toll-free 800-632-9700 (Denver/Boulder), 844-201-5824 (Northern Colorado), or 888-681-7878 (Southern Colorado), (TTY: 711).

How to obtain authorization: You or someone on your behalf must call us at 303-338-3800 or toll-free 800-632-9700 (Denver/Boulder), 844-201-5824 (Northern Colorado), or 888-681-7878 (Southern Colorado), (TTY 711) (these telephone numbers are also on the back of your ID card) to:

• Request authorization for post-stabilization care before you obtain the care from a non-Plan provider if it is reasonable to do so (otherwise, call us as soon as reasonably possible).

• Notify us that you have been admitted to a non-Plan hospital or a hospital with whom we have contracted for emergency services.

We will decide whether to make arrangements for necessary continued care where you are, or to transfer you to a facility we designate. By notifying us of your hospitalization as soon as possible, you will protect yourself from potential liability for payment for services you receive after transfer to one of our facilities would have been possible.



Emergency within our service area High Option Standard Option Basic Option • Emergency care at a Plan urgent care center • Urgent care at a Plan urgent care center • Urgent care delivered through interactive

video • Urgent care provided in your home

$30 per visit $40 per visit $50 per visit

• Emergency care as an outpatient at a hospital, including physicians' services

• Urgent care at a Plan emergency room

$300 per visit $350 per visit after the deductible


Notes: • Interactive video visits may be limited by

provider type and/or location. • We waive your emergency room copayment

on the High and Standard Options if you are directly admitted to a Plan hospital as an inpatient. Your inpatient admission copayment will still apply (See Section 5(c)).

Emergency within our service area - continued on next page




Emergency within our service area (cont.)


• Transfers to an observation bed or observation status do not qualify as an admission to a hospital and your emergency room copayment will not be waived.

Not covered: • Elective care or non-emergency care• Urgent care at a non-Plan urgent care center


Emergency outside our service area High Option Standard Option Basic Option • Emergency care at an urgent care center • Urgent care at an urgent care center

$30 per visit $40 per visit $50 per visit

• Emergency care as an outpatient at a hospital, including physicians' services

• Urgent care at an emergency room

$300 per visit $350 per visit after the deductible


Notes: • We waive your emergency room copayment

if you are directly admitted to a hospital as an inpatient. Your inpatient hospital copayment will still apply (See Section 5(c)).

• Transfers to an observation bed or observation status do not qualify as an admission to a hospital and your emergency room copayment will not be waived.

• See Section 5(h) for travel benefit coverage of continuing or follow-up care.

Not covered: • Elective care or non-emergency care• Follow-up care recommended by non-Plan

providers that has not been approved by the Plan or provided by Plan providers

• Emergency care provided outside the service area if the need for care could have been foreseen before leaving the service area

• Medical and hospital costs resulting from a normal full-term delivery of a baby outside the service area





Ambulance High Option Standard Option Basic Option Licensed ambulance service when medically necessary.

Notes: • See Section 5(c) for non-emergency service. • Trip means any time an ambulance is

summoned on your behalf.

$150 per trip $200 per trip 20% of our allowance up to $500 per trip

Not covered: • Trips we determine are not medically

necessary• Transportation by car, taxi, bus, gurney van,

wheelchair van, minivan, and any other type of transportation (other than a licensed ambulance), even if it is the only way to travel to a provider or facility



Section 5(e). Mental Health and Substance Use Disorder Benefits



• Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and we cover them only when we determine they are clinically appropriate to treat your condition.

• Plan providers must provide or arrange your care.

• Please call our Behavioral Health Department if you have urgent mental health concerns. Call us at 303-471-7700 in Denver/Boulder, 866-359-8299 in Northern Colorado, or 866-702-9026 in Southern Colorado, (TTY 711), 8:30 a.m. to 5 p.m., Monday through Friday.

• The Standard Option plan’s calendar year deductible is $150 per person ($300 per family). The Basic Option plan’s calendar year deductible is ($500 per person and $1,000 per family). The calendar year deductible applies to some benefits in this Section. We added "after the deductible" when the calendar year deductible applies.





Professional services High Option Standard Option Basic Option We cover professional services recommended by a Plan mental health or substance use disorder treatment provider that are covered services, drugs, and supplies described in this brochure.

Notes: • We cover the services only when we

determine that the care is clinically appropriate to treat your condition.

• OPM will generally not order us to pay or provide one clinically appropriate treatment in favor of another.

Your cost-sharing responsibilities are not greater than for other illnesses or conditions.



Diagnosis and treatment of psychiatric conditions, mental illness, or disorders. Services include: • Diagnostic evaluation • Treatment and counseling (including group

and individual therapy visits) • Crisis intervention and stabilization for acute

episodes • Medication evaluation and management • Applied Behavior Analysis (ABA) Therapy

for the treatment of autism spectrum disorder

$20 per individual therapy office visit

$10 per group therapy office visit


$30 per individual therapy office visit (nothing for children through age 17)

$15 per group therapy office visit (nothing for children through age 17)




Professional services - continued on next page 64 2020 Kaiser Foundation Health Plan of Colorado High, Standard and Basic Option Section 5(e)



Professional services (cont.) High Option Standard Option Basic Option Diagnosis and treatment of alcoholism and drug use. Services include: • Detoxification (medical management of

withdrawal from the substance) • Treatment and counseling (including

individual and group therapy visits) • Rehabilitative care

Notes: • You may see a Plan mental health or

substance use provider for these services without a referral from your primary care provider. See Section 3, How You Get Care, for information about services requiring our prior approval.

• Your Plan mental health or substance use provider will develop a treatment plan to assist you in improving or maintaining your condition and functional level, or to prevent relapse and will determine which diagnostic and treatment services are appropriate for you.





$15 per group therapy office visit (nothing for children through age 17)





Procedures received during an office visit Nothing after you pay the office visit copayment

Nothing after you pay the office visit copayment

20% of our allowance after the deductible in addition to the office visit copayment

Methadone/Suboxone treatment program $20 every thirty days $30 every thirty days (nothing for children through age 17)

$20 every thirty days

Inpatient hospital or other covered facility


• Inpatient psychiatric or substance use care • Psychiatric and substance use care in a

residential treatment center

Note: All inpatient admissions require approval by a Plan mental health or substance use physician.

$500 per day up to $1,000 maximum per admission

$750 per admission after the deductible


65 2020 Kaiser Foundation Health Plan of Colorado High, Standard and Basic Option Section 5(e)



Outpatient hospital or other covered facility


• Partial hospitalization, day treatment and intensive outpatient psychiatric treatment programs

• Day treatment programs for substance use

Note: All psychiatric and substance use treatment programs require approval by a Plan mental health or substance use physician.




Not covered High Option Standard Option Basic Option Not covered: • Care that is not clinically appropriate for the

treatment of your condition• Intelligence, IQ, aptitude ability, learning

disorders, or interest testing not necessary to determine the appropriate treatment of a psychiatric condition

• Evaluation or therapy on court order or as a condition of parole or probation, or otherwise required by the criminal justice system, unless determined by a Plan physician to be medically necessary and appropriate

• Services that are custodial in nature • Services rendered or billed by a school or a

member of its staff • Services provided under a federal, state, or

local government program • Psychoanalysis or psychotherapy credited

toward earning a degree or furtherance of education or training regardless of diagnosis or symptoms


66 2020 Kaiser Foundation Health Plan of Colorado High, Standard and Basic Option Section 5(e)

Section 5(f). Prescription Drug Benefits



• We cover prescribed drugs and medications, as described in the chart beginning on the next page.


• There is no pharmacy deductible.

• Federal law prevents the pharmacy from accepting unused medications.


There are important features you should be aware of. These include:

• Who can write your prescription. A licensed Plan provider or licensed dentist must prescribe your medication. We cover prescriptions written by a non-Plan provider or filled at a non-Plan pharmacy only for emergencies or out-of-area urgent care.

• Where you can obtain them. Where you obtain prescription drugs differs based on the service area where you receive your care. - Denver/Boulder. You must fill the prescription at a Plan pharmacy or through the Plan mail order program. - Northern Colorado. You must fill the prescription at a Plan pharmacy, a network pharmacy or through the Plan mail

order program. - Southern Colorado. You may obtain all prescriptions at a Plan pharmacy or through the Plan mail order program. You

may obtain a non-maintenance prescription or a first fill of your maintenance prescription at a network pharmacy, then you must obtain all refills of your maintenance prescription at a Plan medical office pharmacy or through the Plan mail order program only. Maintenance medications are taken regularly for ongoing conditions. Non-maintenance medications are typically prescribed for one-time or urgent conditions, such as antibiotics or for pain.

Regardless of where you receive your care, you may order prescription refills through our website at kp.org/rxrefill if the prescription was originally filled by a Kaiser Permanente pharmacy, or by calling 866-523-6059, (TTY:711) if the prescription was originally filled by a network pharmacy. If you order through the Plan mail order program, your refills will be mailed by First Class U.S. Mail at no charge to you for postage and handling. You should receive your prescription within 7-10 days. Prescribed over-the-counter medications must be filled at a Kaiser Permanente pharmacy. You can get information about our mail order program on kp.org or Member Services at 303-338-3800 or toll-free at 800-632-9700 (Denver/Boulder), 844-201-5824 (Northern Colorado), or 888-681-7878 (Southern Colorado), (TTY: 711).

We cover prescriptions written by a non-Plan provider or filled at a non-Plan pharmacy only for covered emergencies as specified in Section 5(d), Emergency Services/Accidents. Plan members called to active military duty (or members in time of national emergency), who need to obtain prescribed medications, should contact our Member Service Call Center at 303-338-4503. Your refills will be mailed by First Class U.S. Mail at no charge to you for postage and handling. You should receive your prescription within 7-10 days. We cover prescriptions written by a non-Plan provider or filled at a non-Plan pharmacy only for covered emergencies as specified in Section 5(d), Emergency Services/Accidents. Plan members called to active military duty (or members in time of national emergency), who need to obtain prescribed medications, should call 303-338-4503.

• We use a formulary. The medications included in our drug formulary are chosen by a group of Kaiser Permanente physicians, pharmacists and other Plan providers who participate in pharmacy and therapeutics committees. The committees meet regularly to consider adding and removing prescription drugs on the drug formulary based on new information or drugs that become available. Your provider may request an exception for us to cover non-formulary drugs (those not listed on our drug formulary for your condition). You will be charged your applicable non-formulary drug copayment. For more information on our prescription drug FEHB formulary, visit kp.org/formulary or call Member Services at 303-338-3800 or toll-free 800-632-9700 (Denver/Boulder), 844-201-5824 (Northern Colorado), or 888-681-7878 (Southern Colorado), (TTY 711).

67 2020 Kaiser Foundation Health Plan of Colorado High, Standard and Basic Option Section 5(f)


You pay applicable drug cost-sharing based on the tier a drug is in. Our drugs are categorized into four tiers: - Tier 1: Preferred generic drugs. Generic drugs are produced and sold under their generic names after the patent of the

brand-name drug expires. Although the price is usually lower, the quality of generic drugs is the same as brand-name drugs. Generic drugs are also just as effective as brand-name drugs. The Food and Drug Administration (FDA) requires that a generic drug contain the same active drug ingredient in the same amount as the brand-name drug. Preferred generic drugs are listed on our drug formulary.

- Tier 2: Preferred brand-name drugs. Brand-name drugs are produced and sold under the original manufacturer's brand name. Preferred brand-name drugs are listed on our drug formulary.

- Tier 3: Non-preferred generic and brand-name drugs. Non-preferred generic and brand-name drugs are not listed on our drug formulary.

- Tier 4: Specialty drugs. Specialty drugs are high-cost drugs that are on our specialty drug list.

If our allowance for the drug, supply, or supplement is less than the copayment, you will pay the lesser amount. Items can change tiers at any time, in accord with formulary guidelines, which may impact the cost-sharing you pay (for example, if a brand-name drug is added to the specialty drug list, you will pay the cost-sharing that applies to drugs on the specialty drug tier, not the cost-sharing for drugs on the brand-name drug tier).

• These are the dispensing limitations. We provide up to a 30-day supply for most drugs prescribed and obtained from a Plan pharmacy. Refills of prescribed maintenance drugs may be obtained in a Plan pharmacy up to a 90-day supply for three copayments or through our mail order program for two copayments. For prescribed contraceptives, you may obtain up to a three-month supply for the first dispensing and up to a twelve-month supply for refills, or a prescribed vaginal contraceptive ring intended to last for a three-month period, at a Plan pharmacy or through our mail-order program. We cover episodic drugs prescribed to treat sexual dysfunction disorders up to a maximum of 8 doses in any 30-day period or 24 doses in any 90-day period. Most drugs can be mailed from our mail order pharmacy. Some drugs (for example, drugs that are extremely high cost, require special handling, have standard packaging, or requested to be mailed outside the state of Colorado) may not be eligible for mailing and/or a mail order discount. The pharmacy may reduce the day supply dispensed to a 30-day supply in any 30-day period if the pharmacy determines that the item is in limited supply in the market or for specific drugs (your Plan pharmacy can tell you if a drug you take is one of these drugs).

• A generic equivalent will be dispensed if it is available, unless your Plan provider specifically requires a brand-name drug. If you request a brand-name drug on the formulary when your Plan provider has prescribed an approved generic drug, you pay your brand-name drug copayment plus the difference in price between the generic drug and your requested brand-name drug.

• Why use generic drugs? Typically generic drugs cost you and us less money than a brand-name drug. Under federal law, generic and brand-name drugs must meet the same standards for safety, purity, strength, and effectiveness.

• When you do have to file a claim. You do not have to file a claim when you receive drugs from a Plan pharmacy. You have to file a claim when you receive drugs from a non-Plan pharmacy for a covered out-of-area emergency as specified in Section 5(d), Emergency Services/Accidents. For information about how to file a claim, see Section 7, Filing a Claim for Covered Services.

Benefit Description You pay Covered medications and supplies High Option Standard Option Basic Option

We cover the following medications and supplies prescribed by a Plan physician or dentist and obtained from a Plan pharmacy or through our mail order program: • Drugs and medications that, by federal law,

require a physician’s prescription for their purchase, except those listed as Not covered

• Insulin • Disposable needles and syringes for the

administration of covered medications, other than insulin as specified below

$15 for preferred generic drugs;

$40 for preferred brand-name drugs;

$60 for non-preferred drugs; for up to a 30-day supply at a Plan pharmacy

$100 for specialty drugs









Covered medications and supplies - continued on next page 68 2020 Kaiser Foundation Health Plan of Colorado High, Standard and Basic Option Section 5(f)


Benefit Description You pay Covered medications and supplies (cont.)


• Growth hormone • Chemotherapy drugs

Notes: • For information about mail order discounts,

see "These are the dispensing limitations" in the introduction to Section 5(f).

• You will be charged your applicable generic or brand name drug copayment depending on the compound drug's main ingredient, whether the main ingredient is a generic or brand name drug.

• A compound drug is one in which two or more drugs or pharmaceutical agents are combined together to meet the requirements of a prescription.

• Growth hormone requires our prior approval. See Section 3, You need prior Plan approval for certain services.













Women's contraceptive drugs and devices: • Diaphragms and cervical caps • Oral contraceptive drugs • Prescribed FDA approved over-the-counter

women's contraceptives and devices


Diabetic supplies, limited to: • Glucose test strips • Home glucose monitoring supplies • Acetone test tablets • Disposable needles and syringes for the

administration of covered insulin


Medical foods for use in the home: • For individuals unable to absorb or digest

food • Includes enteral and parenteral elemental

dietary formulas and amino acid modified product for treatment of inborn errors of metabolism

$3 per product per day $3 per product per day $3 per product per day

• Sexual dysfunction drugs 50% of our allowance 50% of our allowance 50% of our allowance

• Immunosuppressant drugs after a transplant $40 per prescription or refill

$40 per prescription or refill

$40 per prescription or refill

• Intravenous fluids and medications for home use


Covered medications and supplies - continued on next page



Benefit Description You pay Covered medications and supplies (cont.)


• Prescribed tobacco cessation/E-cigarette medications, including prescribed over-the-counter medications, approved by the FDA to treat tobacco/e-cigarette dependence

Note: Over-the-counter medications require a prescription and must be filled at a Kaiser Permanente pharmacy.


Not covered:• Drugs and supplies for cosmetic purposes • Drugs to enhance athletic performance • Prescriptions filled at a non-Plan pharmacy,

except for emergencies as described in Section 5(d), Emergency Services/Accidents

• Vitamins, nutritional and herbal supplements that can be purchased without a prescription, unless they are included in our drug formulary or listed as covered above.

• Nonprescription drugs, unless they are included in our drug formulary or listed as covered above

• Nonprescription drugs, including prescription drugs for which there is a nonprescription equivalent available

• Medical supplies such as dressings and antiseptics, except as listed above

• Drugs to shorten the duration of the common cold

• Any requested packaging of drugs other than the dispensing pharmacy’s standard packaging

• Replacement of lost, stolen or damaged prescription drugs and accessories

• Drugs related to non-covered services• Drugs for the promotion, prevention, or

other treatment of hair loss or growth • Drugs used in the treatment of weight

management




Benefit Description You pay Preventive Care medications High Option Standard Option Basic Option

Prescribed medications, including over-the-counter medications, required to be covered by group health plans at no cost share by federal health care reform (the Affordable Care Act and implementing regulations), such as: • Aspirin to reduce the risk of heart attack • Oral fluoride for children to reduce the risk

of tooth decay • Folic acid for women to reduce the risk of

birth defects • Medications to reduce the risk of breast

cancer

Notes: • Over-the-counter medications require a

prescription and must be filled at a Kaiser Permanente pharmacy.

• For current recommendations go to www.uspreventiveservicestaskforce.org/BrowseRec/Index/browse-recommendations


Not covered:• Prescriptions filled at a non-Plan pharmacy,

except for emergencies as described in Section 5(d), Emergency services/accidents

• Vitamins, nutritional and herbal supplements that can be purchased without a prescription, unless they are included in our drug formulary or listed as covered above

• Nonprescription drugs, unless they are included in our drug formulary or listed as covered above

• Prescription drugs not on our drug formulary, unless approved through an exception process

• Any requested packaging of drugs other than the dispensing pharmacy’s standard packaging

• Replacement of lost, stolen, or damaged prescription drugs and accessories

• Drugs related to non-covered services



Section 5(g). Dental Benefits



• Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.

• If you are enrolled in a Federal Employees Dental/Vision Insurance Program (FEDVIP) Dental Plan, your FEHB Plan will be First/Primary payor of any Benefit payments and your FEDVIP Plan is secondary to your FEHB Plan. See Section 9, Coordinating Benefits with Medicare and Other Coverage.

• Plan providers must provide or arrange for your care.

• There is no deductible on the High Option.

• The Standard Option plan's calendar year deductible is $150 per person ($300 per family). The Basic Option plan’s calendar year deductible is $500 per person ($1,000 per family). The calendar year deductible applies to some benefits in this Section. We added "after the deductible" when the calendar year deductible applies.

• We cover hospitalization for dental procedures only when a non-dental physical impairment exists which makes hospitalization necessary to safeguard the health of the patient. See Section 5(c) for inpatient hospital benefits. We do not cover the dental procedure unless it is described below.


Benefit Description You Pay Accidental injury benefit High Option Standard Option Basic Option

We cover services to promptly repair (but not replace) a sound, natural tooth, if: • Damage is due to an accidental injury from

trauma to the mouth from violent contact with an external object,

• The tooth has not been restored previously, except in a proper manner, and

• The tooth has not been weakened by decay, periodontal disease, or other existing dental pathology.

Note: Services will be covered only when started within 30 days and provided within one year of the accidental injury.

$20 per visit 10% of our allowance after the deductible


Not covered: Services for conditions caused by an accidental injury occurring before your eligibility date.


Dental benefits

We have no other dental benefits.

72 2020 Kaiser Foundation Health Plan of Colorado High, Standard and Basic Option Section 5(g)

Section 5(h). Wellness and Other Special Features


Feature Description Under the flexible benefits option, we determine the most effective way to provide services. • We may identify medically appropriate alternatives to regular contract benefits as a

less costly alternative. If we identify a less costly alternative, we will ask you to sign an alternative benefits agreement that will include all of the following terms in addition to other terms as necessary. Until you sign and return the agreement, regular contract benefits will continue.

• Alternative benefits will be made available for a limited time period and are subject to our ongoing review. You must cooperate with the review process.

• By approving an alternative benefit, we do not guarantee you will get it in the future. • The decision to offer an alternative benefit is solely ours, and except as expressly

provided in the agreement, we may withdraw it at any time and resume regular contract benefits.

• If you sign the agreement, we will provide the agreed-upon alternative benefits for the stated time period (unless circumstances change). You may request an extension of the time period, but regular contract benefits will resume if we do not approve your request.

• Our decision to offer or withdraw alternative benefits is not subject to OPM review under the disputed claims process. However, if at the time we make a decision regarding alternative benefits, we also decide that regular contract benefits are not payable, then you may dispute our regular contract benefits decision under the OPM disputed claims process (see Section 8).

Flexible benefits option

Besides in-person care at our medical offices, you have options to connect to care: • By phone. Where telephone appointments are available, you can save yourself a trip

to our medical offices and talk with your doctor by phone. If you’re not sure what kind of care you need, you can also call our advice nurses 24 hours a day, 7 days a week.

• By email. For nonurgent questions, you can simply email your doctor’s office. You can also email a Kaiser Permanente pharmacist for questions about medications, or Member Services for questions about your benefits.

• By video. For some conditions and symptoms, you can connect with your doctor face-to-face by video.

Your cost-sharing for telephone, email and video visits may differ from cost-sharing described in this FEHB brochure for in-person care at our medical offices.

Options for care

The Centers of Excellence program began in 1987. As new technologies proliferate and become the standard of care, Kaiser Permanente refers members to contracted “Centers of Excellence” for certain specialized medical procedures.

We have developed a nationally contracted network of Centers of Excellence for organ transplantation, which consists of medical facilities that have met stringent criteria for quality care in specific procedures. A national clinical and administrative team has developed guidelines for site selection, site visit protocol, volume and survival criteria for evaluation and selection of facilities. The institutions have a record of positive outcomes and exceptional standards of quality.

Centers of Excellence

We provide TTY/text telephone numbers at: 711. Sign language services are also available.

Services for the deaf, hard of hearing or speech impaired

73 2020 Kaiser Foundation Health Plan of Colorado High, Standard and Basic Option Section 5(h)


Feature Description When you visit a different Kaiser Foundation Health Plan service area, you can receive visiting member services from designated providers in that area. Visiting member services are subject to the terms, conditions and cost-sharing described in this FEHB brochure. Certain services are not covered as a visiting member.

For more information about receiving visiting member services, including provider and facility locations in other Kaiser Permanente service areas, please call our Away from Home Travel Line at 951-268-3900 or visit kp.org/travel.

Services from other Kaiser Permanente regions

We provide a limited benefit to dependents under the age of 26, who are temporarily outside Kaiser Permanente’s service areas and within the United States. These benefits are in addition to your emergency benefits and will be applied before your travel benefit.

We cover routine, continuing and follow-up medical care as follows: • Up to 5 office visits per year (combined visit limit between primary care, specialty

care, outpatient mental health and substance use disorder care, gynecology care, preventive care and immunizations, hearing exams, and allergy injections). You pay $20 (High and Basic Options) or $30 (Standard Option) per visit.

• Up to 5 diagnostic X-rays per year. You pay 20% of our allowance (High Option) or 20% of our allowance after you have met the calendar year deductible (Standard and Basic Option).

• Up to 5 prescription drug fills. You pay cost-sharing of 50% of our allowance. • Up to 5 therapy visits per year (combined visit limit between physical, occupational,

and speech therapy). You pay $20 (High and Basic Options) or $30 (Standard Option) per visit.

File claims as shown in Section 7. For more information about this benefit, call 303-338-3800 or toll-free 800-632-9700 (Denver/Boulder), 844-201-5824 (Northern Colorado), or 888-681-7878 (Southern Colorado), (TTY: 711).

The following are not included in your dependent out-of-area benefit:• Dental services • Transplants and transplant follow-up care• Services provided outside the United States• Laboratory, office procedures and office administered drugs and devices, except for

allergy injections and preventive immunizations• Allergy evaluation, routine prenatal and postpartum visits, chiropractic services,

acupuncture services, applied behavior analysis (ABA), pediatric dental, hearing tests, hearing aids, home health visits, hospice services, and travel immunizations

• Special diagnostic procedures such as CT, MRI, or PET scans• Any and all services not listed in "Coverage" section of this benefit

Dependent out-of-area benefit

Kaiser Permanente’s travel benefit for Federal employees provides you with outpatient follow-up and/or continuing medical and mental health and substance use disorder care when you are temporarily (for example, on a temporary work assignment or attending school) outside your home service area by more than 100 miles and outside of any other Kaiser Permanente service area. These benefits are in addition to your emergency services/accident benefit and include: • Outpatient follow-up care necessary to complete a course of treatment after a covered

emergency. Services include removal of stitches, a catheter, or a cast.

Travel benefit



• Outpatient continuing care for covered services for conditions diagnosed and treated within the previous 12 months by a Kaiser Permanente health care provider or affiliated Plan provider. Services include dialysis and prescription drug monitoring.

You pay $25 for each follow-up or continuing care office visit. This amount will be deducted from the reimbursement we make to you. We limit our payment for this travel benefit to no more than $1,200 each calendar year. For more information about this benefit call the Travel Benefit Information Line at 800-632-9700 (TTY: 711). File claims as shown in Section 7.

The following are a few examples of services not included in your travel benefits coverage:• Non-emergency hospitalization• Infertility treatments• Medical and hospital costs resulting from a normal full-term delivery of a baby

outside the service area• Transplants• Durable medical equipment (DME)• Prescription drugs• Home health services

Take steps to improve your well-being by completing the Kaiser Permanente Total Health Assessment and a biometric screening. FEHB subscribers and their enrolled spouses (age 18 and over) are eligible for the following reward: • $150 for completing a confidential, online, Total Health Assessment (available in

English or Spanish) and being up to date on the following biometric screenings: blood glucose, blood pressure, Body Mass Index (BMI) and total cholesterol. To view and determine the status of your screenings, go to kp.org/feds. If you have not had these screenings recently, you may be required to contact your Kaiser Permanente doctor. You’ll get a picture of your overall health and a customized action plan with tips and resources to improve your well-being.

You must accept the Wellness Program Agreement to be eligible to earn rewards. Please go to kp.org/feds to learn how to earn your reward and to view and track the status of your reward activities.

You must complete the Total Health Assessment and biometric screening during the plan year. We will issue you a Kaiser Permanente Health Payment Card 4-6 weeks after you complete both activities. We will send each eligible member their own debit card.

You may use your Health Payment Card to pay for certain qualified medical expenses, such as: • Copayments for office visits, prescription drugs and other services at Kaiser

Permanente or other providers • Prescription eyeglasses or contacts • Dental services • Over-the-counter medication for certain diseases • Other medical expenses, as permitted by the IRS

Please keep your card for use in the future. As you complete activities, we will add rewards to your card. We will not send you a new card until the card expires. Rewards you earn during this calendar year may be used until March 31 of the next calendar year. Funds are forfeited if you leave this plan.

Rewards



For more information, please go to kp.org/feds. If you have questions about completing a Total Health Assessment or class, you may call us at 1-866-300-9867. If you have questions about your account balance or what expenses the Health Payment Card can be used for, you may call the phone number on the back of your Health Payment Card.


Non-FEHB Benefits Available to Plan Members

The benefits on this page are not part of the FEHB contract or premium, and you cannot file an FEHB disputed claim about them. Fees you pay for these services do not count toward FEHB deductibles or catastrophic protection out-of-pocket maximums. These programs and materials are the responsibility of the Plan and all complaints must follow their guidelines. For additional information, contact the Plan at 303-338-3800 or toll-free 800-632-9700 in Denver/Boulder, 844-201-5824 in Northern Colorado, and 888-681-7878 in Southern Colorado (TTY: 711).

Active&Fit® Program (Available only to Basic Option members) Active&Fit® is a fitness program available to members age 16 and older. You may enroll in a local participating standard fitness facility. You pay $100 per enrollment. Enrollment is for up to one calendar year. You may use a participating fitness club while traveling temporarily outside of the service area by contacting American Specialty Health (ASH) before your trip to register at another gym/facility.

You may enroll online at kp.org/activeandfit, directly with a participating fitness facility or by calling ASH at 877-750-2746, from 6 a.m. to 7 p.m. (Mountain Standard Time), Monday through Friday. Note: Refunds are not given and fees are not prorated (for example if you enroll mid-year, you still pay $100).

The ChooseHealthy® Program As a Kaiser Permanente member, you can use the ChooseHealthy® program (a product of American Specialty Health Administrators, Inc.) to receive a discount for chiropractic, acupuncture, and massage therapy services, as well as register for ASH’s Active&Fit Direct fitness membership program ($25 initiation fee and $25 monthly thereafter) with access to 8,500+ gyms nationwide. ChooseHealthy® also provides complementary access to online resources and tools to help you achieve your health and fitness goals. Learn more at kp.org/choosehealthy or call 877-335-2746.

Dental Benefits FEHB members enrolled in Kaiser Permanente may purchase dental services from Delta Dental of Colorado. You have two plans to choose from and both allow you to choose any dentist you wish, but you usually pay less out of pocket when you visit a Delta Dental PPO dentist. You must submit a separate enrollment for dental benefits and pay an additional premium directly to Delta Dental of Colorado.

For information on covered services, deductibles, cost-sharing, exclusions, limitations, 12-month waiting periods for major and orthodontic services and to enroll, please contact Delta Dental of Colorado for presales information at 877-516-6512 or customer relations at 800-610-0201.

77 2020 Kaiser Foundation Health Plan of Colorado Section 5 Non-FEHB Benefits Available to Plan Members

Section 6. General Exclusions – Services, Drugs and Supplies We Do Not Cover

The exclusions in this section apply to all benefits. There may be other exclusions and limitations listed in Section 5 of this brochure. Although we may list a specific service as a benefit, we will not cover it unless it is medically necessary to prevent, diagnose, or treat your illness, disease, injury, or condition. For information on obtaining prior approval for specific services, such as transplants, see Section 3, You need prior Plan approval for certain services.

We do not cover the following:

• When a service is not covered, all services, drugs or supplies related to the noncovered service are excluded from coverage, except services we would otherwise cover to treat complications of the noncovered service.

• Fees associated with non-payment (including interest), missed appointments and special billing arrangements.

• Care by non-Plan providers except for authorized referrals, emergencies, travel benefit, services from other Kaiser Permanente plans, or dependent coverage outside the service area (see Emergency Services/Accidents and Special Features).

• Services, drugs, or supplies you receive while you are not enrolled in this Plan.

• Services, drugs, or supplies not medically necessary.

• Services, drugs, or supplies not required according to accepted standards of medical, dental, or psychiatric practice.

• Experimental or investigational procedures, treatments, drugs, or devices (see specifics regarding transplants).

• Services, drugs, or supplies related to abortions, except when the life of the mother would be endangered if the fetus were carried to term or when the pregnancy is the result of an act of rape or incest.

• Services, drugs, or supplies you receive from a provider or facility barred from the FEHB Program.

• Services, drugs, or supplies you receive without charge while in active military service.

• Services provided or arranged by criminal justice institutions for members confined therein.


Section 7. Filing a Claim for Covered Services

This section primarily deals with post-service claims (claims for services, drugs or supplies you have already received). See Section 3 for information on prior Plan approval and pre-service claims procedures (services, drugs or supplies requiring prior Plan approval), including urgent care claims procedures.

When you see Plan providers, receive services at Plan hospitals and facilities, or fill your prescription drugs at Plan pharmacies, you will not have to file claims. Just present your identification card and pay your copayment, coinsurance, or deductible.

You may need to file a claim when you receive a service or item from a non-plan provider or at a non-Plan facility. This includes services such as out-of-network emergency services, out-of-area urgent care and services covered under the travel benefit. Check with the provider to determine if they can bill us directly. Filing a claim does not guarantee payment. If you need to file the claim, here is the process:

In most cases, providers and facilities file claims for you. Providers must file on the form CMS-1500, Health Insurance Claim Form. Facilities will file on the UB-04 form. For claims questions and assistance, call us at 303-338-3600 or toll-free 800-382-4661 in Denver/Boulder, 800-382-4661 in Northern Colorado, and 888-681-7878 in Southern Colorado, (TTY: 711).

When you must file a claim - such as for services you received outside of the Plan’s service area – submit it on the CMS-1500 or a claim form that includes the information shown below. Bills and receipts should be itemized and show: • Covered member’s name, date of birth, address, phone number and ID number • Name and address of the provider or facility that provided the service or supply • Dates you received the services or supplies • Diagnosis • Type of each service or supply • The charge for each service or supply • Follow up services rendered out-of-area • A copy of the explanation of benefits, payments, or denial from any primary payor –

such as the Medicare Summary Notice (MSN) • Receipts, if you paid for your services

Note: Canceled checks, cash register receipts, or balance due statements are not acceptable substitutes for itemized bills.

Submit your claims to:

Denver/Boulder and Northern Colorado areas:Claims Department Kaiser Foundation Health Plan of Colorado P.O. Box 373150 Denver, CO 80237-3150

Southern Colorado area:Claims Department Kaiser Foundation Health Plan of Colorado P.O. Box 372910 Denver, CO 80237-6910

Medical, hospital, and drug benefits

Send us all of the documents for your claim as soon as possible. You must submit the claim by December 31 of the year after the year you received the service, unless timely filing was prevented by administrative operations of Government or legal incapacity, provided the claim was submitted as soon as reasonably possible.

Deadline for filing your claim


We will notify you of our decision within 30 days after we receive your post-service claim. If matters beyond our control require an extension of time, we may take up to an additional 15 days for review and we will notify you before the expiration of the original 30-day period. Our notice will include the circumstances underlying the request for the extension and the date when a decision is expected.

If we need an extension because we have not received necessary information from you, our notice will describe the specific information required and we will allow you up to 60 days from the receipt of the notice to provide the information.

If you do not agree with our initial decision, you may ask us to review it by following the disputed claims process detailed in Section 8 of this brochure.

Post-Service Claims

You may designate an authorized representative to act on your behalf for filing a claim or to appeal claims decisions to us. For urgent care claims, we will permit a health care professional with knowledge of your medical condition to act as your authorized representative without your express consent. For the purposes of this section, we are also referring to your authorized representative when we refer to you.

Authorized Representative

If you have any claim or dispute that is not governed by the Disputed Claims Process with OPM described in Section 8, then all such claims and disputes of any nature between you and the Plan, including but not limited to malpractice claims, shall be resolved by binding arbitration, subject to the Plan's Arbitration procedures. The Plan has the information that describes the arbitration process. Contact our Resolve Program at 303-344-7298 for copies of our requirements. These will explain how you can begin the binding arbitration process.

Binding arbitration

If you live in a county where at least 10 percent of the population is literate only in a non-English language (as determined by the Secretary of Health and Human Services), we will provide language assistance in that non-English language. You can request a copy of your Explanation of Benefits (EOB) statement, related correspondence, oral language services (such as telephone customer assistance), and help with filing claims and appeals (including external reviews) in the applicable non-English language. The English versions of your EOBs and related correspondence will include information in the non-English language about how to access language services in that non-English language.

Any notice of an adverse benefit determination or correspondence from us confirming an adverse benefit determination will include information sufficient to identify the claim involved (including the date of service, the health care provider, and the claim amount, if applicable), and a statement describing the availability, upon request, of the diagnosis and procedure codes.

Notice Requirements


Section 8. The Disputed Claims Process

You may appeal directly to the Office of Personnel Management (OPM) if we do not follow required claims processes. For more information or to make an inquiry about situations in which you are entitled to immediately appeal to OPM, including additional requirements not listed in Sections 3, 7 and 8 of this brochure, please call Member Services at the phone number found on your ID card, Plan brochure, or Plan website.

Please follow this Federal Employees Health Benefits Program disputed claims process if you disagree with our decision on your post-service claim (a claim where services, drugs or supplies have already been provided). In Section 3 If you disagree with our pre-service claim decision, we describe the process you need to follow if you have a claim for services, referrals, drugs or supplies that must have prior Plan approval, such as inpatient hospital admissions.

To help you prepare your appeal, you may arrange with us to review and copy, free of charge, all relevant materials and Plan documents under our control relating to your claim, including those that involve any expert review(s) of your claim. To make your request, please contact Member Services by writing to Kaiser Foundation Health Plan of Colorado, Member Services Department, 2500 South Havana Street, Aurora, Colorado 80014-1622 or calling 303-338-3800 or toll-free at 800-632-9700 (Denver/Boulder), 844-201-5824 (Northern Colorado), or 888-681-7878 (Southern Colorado), (TTY 711).

Our reconsideration will take into account all comments, documents, records, and other information submitted by you relating to the claim, without regard to whether such information was submitted or considered in the initial benefit determination.

When our initial decision is based (in whole or in part) on a medical judgment (i.e., medical necessity, experimental/investigational), we will consult with a health care professional who has appropriate training and experience in the field of medicine involved in the medical judgment and who was not involved in making the initial decision.

Our reconsideration will not take into account the initial decision. The review will not be conducted by the same person, or his/her subordinate, who made the initial decision.

We will not make our decisions regarding hiring, compensation, termination, promotion, or other similar matters with respect to any individual (such as a claims adjudicator or medical expert) based upon the likelihood that the individual will support the denial of benefits.

Step Description Ask us in writing to reconsider our initial decision. You must:

a) Write to us within 6 months from the date of our decision; and

b) Send your request to us at: Appeals Program, Kaiser Foundation Health Plan of Colorado, P.O. Box 378066, Denver, CO 80237-8066; and

c) Include a statement about why you believe our initial decision was wrong, based on specific benefit provisions in this brochure; and

d) Include copies of documents that support your claim, such as physicians’ letters, operative reports, bills, medical records, and explanation of benefits (EOB) forms.

We will provide you, free of charge and in a timely manner, with any new or additional evidence considered, relied upon, or generated by us or at our direction in connection with your claim and any new rationale for our claim decision. We will provide you with this information sufficiently in advance of the date that we are required to provide you with our reconsideration decision to allow you a reasonable opportunity to respond to us before that date. However, our failure to provide you with new evidence or rationale in sufficient time to allow you to timely respond shall not invalidate our decision on reconsideration. You may respond to that new evidence or rationale at the OPM review stage described in step 4.

1

In the case of a post-service claim, we have 30 days from the date we receive your request to:

a) Pay the claim or 2


b) Write to you and maintain our denial or

c) Ask you or your provider for more information.

You or your provider must send the information so that we receive it within 60 days of our request. We will then decide within 30 more days.

If we do not receive the information within 60 days we will decide within 30 days of the date the information was due. We will base our decision on the information we already have. We will write to you with our decision.

If you do not agree with our decision, you may ask OPM to review it.

You must write to OPM within: • 90 days after the date of our letter upholding our initial decision; or • 120 days after you first wrote to us - if we did not answer that request in some way within 30 days; or • 120 days after we asked for additional information.

Write to OPM at: United States Office of Personnel Management, Healthcare and Insurance, Federal Employee Insurance Operations, FEHB 3, 1900 E Street NW, Washington, DC 20415-3630.

Send OPM the following information: • A statement about why you believe our decision was wrong, based on specific benefit provisions in this

brochure; • Copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical

records, and explanation of benefits (EOB) forms; • Copies of all letters you sent to us about the claim; • Copies of all letters we sent to you about the claim; • Your daytime phone number and the best time to call; and • Your email address, if you would like to receive OPM's decision via email. Please note that by providing

your email address, you may receive OPM's decision more quickly.

Note: If you want OPM to review more than one claim, you must clearly identify which documents apply to which claim.

Note: You are the only person who has a right to file a disputed claim with OPM. Parties acting as your representative, such as medical providers, must include a copy of your specific written consent with the review request. However, for urgent care claims, a health care professional with knowledge of your medical condition may act as your authorized representative without your express consent.

Note: The above deadlines may be extended if you show that you were unable to meet the deadline because of reasons beyond your control.

3

OPM will review your disputed claim request and will use the information it collects from you and us to decide whether our decision is correct. OPM will send you a final decision within 60 days. There are no other administrative appeals.

If you do not agree with OPM’s decision, your only recourse is to sue. If you decide to file a lawsuit, you must file the suit against OPM in Federal court by December 31 of the third year after the year in which you received the disputed services, drugs, or supplies or from the year in which you were denied precertification or prior approval. This is the only deadline that may not be extended.

OPM may disclose the information it collects during the review process to support their disputed claim decision. This information will become part of the court record.

4


You may not file a lawsuit until you have completed the disputed claims process. Further, Federal law governs your lawsuit, benefits, and payment of benefits. The Federal court will base its review on the record that was before OPM when OPM decided to uphold or overturn our decision. You may recover only the amount of benefits in dispute.

Note: If you have a serious or life-threatening condition (one that may cause permanent loss of bodily functions or death if not treated as soon as possible), and you did not indicate that your claim was a claim for urgent care, then call us at 303-344-7933 or toll-free at 888-370-9858, (TTY: 711). We will expedite our review (if we have not yet responded to your claim); or we will inform OPM so they can quickly review your claim on appeal. You may call OPM’s FEHB 3 at 202-606-0755 between 8 a.m. and 5 p.m. Eastern Time.

Please remember that we do not make decisions about plan eligibility issues. For example, we do not determine whether you or a dependent is covered under this Plan. You must raise eligibility issues with your Agency personnel/payroll office if you are an employee, your retirement system if you are an annuitant or the Office of Workers' Compensation Programs if you are receiving Workers' Compensation benefits.


Section 9. Coordinating Benefits with Medicare and Other Coverage

You must tell us if you or a covered family member has coverage under any other health plan or has automobile insurance that pays health care expenses without regard to fault. This is called “double coverage.”

When you have double coverage, one plan normally pays its benefits in full as the primary payor and the other plan pays a reduced benefit as the secondary payor. We, like other insurers, determine which coverage is primary according to the National Association of Insurance Commissioners’ (NAIC) guidelines. For more information on NAIC rules regarding the coordinating of benefits, visit our website at kp.org/feds.

When we are the primary payor, we will pay the benefits described in this brochure.

When we are the secondary payor, we will determine our allowance. After the primary plan pays, we will pay what is left of our allowance, up to our regular benefit. We will not pay more than our allowance. If we are the secondary payor, and you received your services from Plan providers, we may bill the primary carrier.

When you have other health coverage

TRICARE is the health care program for eligible dependents of military persons, and retirees of the military. TRICARE includes the CHAMPUS program. CHAMPVA provides health coverage to disabled Veterans and their eligible dependents. IF TRICARE or CHAMPVA and this Plan cover you, we pay first. See your TRICARE or CHAMPVA Health Benefits Advisor if you have questions about these programs.

Suspended FEHB coverage to enroll in TRICARE or CHAMPVA: If you are an annuitant or former spouse, you can suspend your FEHB coverage to enroll in one of these programs, eliminating your FEHB premium. (OPM does not contribute to any applicable plan premiums.) For information on suspending your FEHB enrollment, contact your retirement office. If you later want to re-enroll in the FEHB Program, generally you may do so only at the next Open Season unless you involuntarily lose coverage under TRICARE or CHAMPVA.

• TRICARE and CHAMPVA

We do not cover services that: • You (or a covered family member) need because of a workplace-related illness or

injury that the Office of Workers’ Compensation Programs (OWCP) or a similar federal or state agency determines they must provide; or

• OWCP or a similar agency pays for through a third-party injury settlement or other similar proceeding that is based on a claim you filed under OWCP or similar laws.

Once OWCP or similar agency pays its maximum benefits for your treatment, we will cover your care. You must use our providers.

• Workers’ Compensation

When you have this Plan and Medicaid, we pay first.

Suspended FEHB coverage to enroll in Medicaid or a similar state-sponsored program of medical assistance: If you are an annuitant or former spouse, you can suspend your FEHB coverage to enroll in one of these state programs, eliminating your FEHB premium. For information on suspending your FEHB enrollment, contact your retirement office. If you later want to re-enroll in the FEHB Program, generally you may do so only at the next Open Season unless you involuntarily lose coverage under the state program.

• Medicaid

We do not cover services and supplies when a local, state, or federal government agency directly or indirectly pays for them.

When other Government agencies are responsible for your care


When you receive money to compensate you for medical or hospital care for injuries or illness caused by another person, you must reimburse us for any expenses we paid. However, we will cover the cost of treatment that exceeds the amount you received in the settlement.

If you do not seek damages you must agree to let us try. This is called subrogation. If you need more information, contact us for our subrogation procedures.

If you obtain a judgment or settlement from or on behalf of a third party who allegedly caused or is responsible for an injury or illness for which you received covered health care services or benefits (“Services”), you must pay us Charges for those Services. “Charges” are: 1) for Services that we pay the provider on a fee-for-service basis, the payments that we made for the Services; and 2) for all other Services, the charges in the provider’s schedule of charges for Services provided to Members less any cost share payments that you made to the provider. Our payments for Services in these circumstances are expressly conditioned on your agreement to comply with these provisions. You are still required to pay cost-sharing to the provider, even if a third party has allegedly caused or is responsible for the injury or illness for which you received Services.

You must also pay us Charges for such Services if you receive or are entitled to receive a recovery from any insurance for an injury or illness alleged to be based on a third party’s or your own fault, such as from uninsured or underinsured motorist coverage, automobile or premises medical payments coverage, or any other first coverage. You must also pay us Charges for such Services if you receive or are entitled to receive recovery from any Workers’ Compensation benefits.

To secure our rights, we will have a lien on and reimbursement right to the on the proceeds of any judgment or settlement you or we obtain. The proceeds of any judgment or settlement that you or we obtain shall first be applied to satisfy our lien, regardless of whether the total amount of the proceeds is less than the actual losses and damages you incurred. Our right to receive payment is not subject to reduction based on attorney fees or costs under the “common fund” doctrine and is fully enforceable regardless of whether you are “made whole” or fully compensated for the full amount of damages claimed.

We are entitled to full recovery regardless of whether any liability for payment is admitted by any person, entity or insurer. We are entitled to full recovery regardless of whether the settlement or judgment received by you identifies the medical benefits provided or purports to allocate any portion of such settlement or judgment to payment of expenses other than medical expenses. We are entitled to recover from any and all settlements, even those designated as for pain and suffering, non-economic damages and/or general damages only.

In order for us to determine the existence of any rights we may have and to satisfy those rights, you must complete and send us all consents, releases, authorizations, assignments, and other documents, including lien forms directing your attorney and any insurer to pay us directly. You may not agree to waive, release, or reduce our rights under this provision without our prior, written consent. You must cooperate in doing what is reasonably necessary to assist us with our right of recovery. You must notify us within 30 days of the date you or someone acting on your behalf notifies anyone, including an insurer or attorney, of your intention to pursue or investigate a claim to recover damages or obtain compensation due to your injury or illness. You must not take any action that may prejudice our right of recovery.

If your estate, parent, guardian, or conservator asserts a claim based on your injury or illness, that person or entity and any settlement or judgment recovered by that person or entity shall be subject to our liens and other rights to the same extent as if you had asserted the claim against the party. We may assign our rights to enforce our liens and other rights.

When third parties cause illness or injuries


We have the option of becoming subrogated to all claims, causes of action, and other rights you may have against a third party or an insurer, government program, or other source of coverage for monetary damages, compensation, or indemnification on account of the injury or illness allegedly caused by the third party. We will be so subrogated as of the time we mail or deliver a written notice of our exercise of this option to you or your attorney, but we will be subrogated only to the extent of the total of Charges for the relevant Services.

Contact us if you need more information about recovery or subrogation.

If you enter into a Surrogacy Agreement, you must reimburse us for covered services you receive related to conception, pregnancy, delivery, or postpartum care in connection with the Surrogacy Agreement, except that the amount you must pay will not exceed the payments or other compensation you and any other payee are entitled to receive under the Surrogacy Agreement. A "Surrogacy Agreement" is one in which a woman agrees to become pregnant and to surrender the baby (or babies) to another person or persons who intend to raise the child (or children), in exchange for payment or compensation for being a surrogate. The "Surrogacy Agreement" does not affect your obligation to pay your cost-sharing for services received, but we will credit any such payments toward the amount you must pay us under this paragraph. We will only cover charges incurred for any services when you have legal custody of the baby and when the baby is covered as a family member under your Self Plus One or Self and Family enrollment (the legal parents are financially responsible for any services that the baby receives).

By accepting services, you automatically assign to us your right to receive payments that are payable to you or any other payee under the Surrogacy Agreement, regardless of whether those payments are characterized as being for medical expenses. To secure our rights, we will also have a lien on those payments and on any escrow account, trust, or any other account that holds those payments. Those payments (and amounts in any escrow account, trust, or other account that holds those payments) shall first be applied to satisfy our lien. The assignment and our lien will not exceed the total amount of your obligation to us under the preceding paragraph.

Within 30 days after entering into a Surrogacy Agreement, you must send written notice of the Agreement, a copy of the Agreement, including the names, addresses, and telephone numbers of all parties involved in the Agreement. You must send this information to:

Patient Business Services Kaiser Foundation Health Plan of Colorado 2500 South Havana Street Aurora, CO 80014-1622

You must complete and send us consents, releases, authorizations, lien forms, and other documents that are reasonably necessary for us to determine the existence of any rights we may have under this "Surrogacy Agreements" section and to satisfy those rights.

If your estate, parent, guardian, or conservator asserts a claim against a third party based on the Surrogacy Agreement, your estate, parent, guardian, or conservator and any settlement or judgment recovered by the estate, parent, guardian, or conservator shall be subject to our liens and other rights to the same extent as if you had asserted the claim against the third party. We may assign our rights to enforce our liens and other rights.

Surrogacy Agreements

Some FEHB plans already cover some dental and vision services. When you are covered by more than one vision/dental plan, coverage provided under your FEHB plan remains as your primary coverage. FEDVIP coverage pays secondary to that coverage. When you enroll in a dental and/or vision plan on BENEFEDS.com or by phone at 877-888-3337, (TTY 877-889-5680), you will be asked to provide information on your FEHB plan so that your plans can coordinate benefits. Providing your FEHB information may reduce your out-of-pocket cost.

When you have Federal Employees Dental and Vision Insurance Plan (FEDVIP) coverage


An approved clinical trial includes a phase I, phase II, phase III, or phase IV clinical trial that is conducted in relation to the prevention, detection, or treatment of cancer or other life-threatening disease or condition and is either Federally funded; conducted under an investigational new drug application reviewed by the Food and Drug Administration; or is a drug trial that is exempt from the requirement of an investigational new drug application.

We will cover the initial evaluation for eligibility and acceptance into a clinical trial and routine care costs not provided by the clinical trial in accordance with Section 5 when Plan physicians provide or arrange for your care. • Routine care costs are costs for routine services such as doctor visits, lab tests, x-rays

and scans, and hospitalizations related to treating the patient’s condition whether the patient is in a clinical trial or is receiving standard therapy. We cover routine care costs not provided by the clinical trial.

The Plan does not cover extra care costs and research costs. • Extra care costs are costs related to taking part in a clinical trial such as additional

tests that a patient may need as part of the trial, but not as part of the patient’s routine care. We do not cover these costs.

• Research costs are costs related to conducting the clinical trial such as research physician and nurse time, analysis of results, and clinical tests performed only for research purposes. These costs are generally covered by the clinical trials. We do not cover these costs.

Clinical trials

When you have Medicare

Medicare is a health insurance program for: • People 65 years of age or older • Some people with disabilities under 65 years of age • People with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a

kidney transplant)

Medicare has four parts: • Part A (Hospital Insurance). Most people do not have to pay for Part A. If you or your

spouse worked for at least 10 years in Medicare-covered employment, you should be able to qualify for premium-free Part A insurance. (If you were a Federal employee at any time both before and during January 1983, you will receive credit for your Federal employment before January 1983). Otherwise, if you are age 65 or older, or under age 65 and disabled, you may be able to buy it. Contact 800-MEDICARE (800-633-4227) (TTY: 877-486-2048) for more information.

• Part B (Medical Insurance). Most people pay monthly for Part B. Generally, Part B premiums are withheld from your monthly Social Security check or your retirement check.

• Part C (Medicare Advantage). You may enroll in a Medicare Advantage plan to get your Medicare benefits. We offer a Medicare Advantage plan, Kaiser Permanente Senior Advantage for Federal Members. Please review the information about Medicare Advantage plans on pages 89-92.

• What is Medicare?


• Part D (Medicare prescription drug coverage). There is a monthly premium for Part D coverage. Before enrolling in Medicare Part D, please review the important disclosure notice from us about the FEHB prescription drug coverage and Medicare. The notice is on the first inside page of this brochure. However, when you are enrolled in Kaiser Permanente Senior Advantage for Federal Members, Part D is included in your plan; no separate premium applies. For people with limited income and resources, extra help in paying for a Medicare prescription drug plan is available. For more information about this extra help, visit the Social Security Administration online at www.socialsecurity.gov, or call them at 800-772-1213 (TTY: 800-325-0778).

The decision to enroll in Medicare is yours. We encourage you to apply for Medicare benefits 3 months before you turn age 65. It’s easy. Just call the Social Security Administration toll-free number 800-772-1213 (TTY 800-325-0778) to set up an appointment to apply. If you do not apply for one or more Parts of Medicare, you can still be covered under the FEHB Program.

If you can get premium-free Part A coverage, we advise you to enroll in it. Most Federal employees and annuitants are entitled to Medicare Part A at age 65 without cost. When you don’t have to pay premiums for Medicare Part A, it makes good sense to obtain the coverage. It can reduce your out-of-pocket expenses as well as costs to the FEHB, which can help keep FEHB premiums down.

Everyone is charged a premium for Medicare Part B coverage. The Social Security Administration can provide you with premium and benefit information. Review the information and decide if it makes sense for you to buy the Medicare Part B coverage. If you do not sign up for Medicare Part B when you are first eligible, you may be charged a Medicare Part B late enrollment penalty of a 10% increase in premium for every 12 months you are not enrolled. If you did not take Part B at age 65 because you were covered under FEHB as an active employee (or you were covered under your spouse's group health insurance plan and he/she was an active employee), you may sign up for Part B (generally without an increased premium) within 8 months from the time you or your spouse stop working or are no longer covered by the group plan. You also can sign up at any time while you are covered by the group plan.

If you are eligible for Medicare, you may have choices in how you get your health care. Medicare Advantage is the term used to describe the various private health plan choices available to Medicare beneficiaries. The information in the next few pages shows how we coordinate benefits with Medicare, depending on whether you are in the Original Medicare Plan or a private Medicare Advantage plan.

• Should I enroll in Medicare?

If you enroll in Medicare Part B, we require you to assign your Medicare Part B benefits to the Plan for its services. Assigning your benefits means you give the Plan written permission to bill Medicare on your behalf for covered services you receive in network. You do not lose any benefits or entitlements as a result of assigning your Medicare Part B benefits.

• If you enroll in Medicare Part B

The Original Medicare Plan (Original Medicare) is available everywhere in the United States. It is the way everyone used to get Medicare benefits and is the way most people get their Medicare Part A and Part B benefits now. You may go to any doctor, specialist, or hospital that accepts Medicare. The Original Medicare Plan pays its share and you pay your share.

All physicians and other providers are required by law to file claims directly to Medicare for members with Medicare Part B, when Medicare is primary. This is true whether or not they accept Medicare.

When you are enrolled in Original Medicare along with this Plan, you still need to follow the rules in this brochure for us to cover your care.

• The Original Medicare Plan (Part A or Part B)


Claims process when you have the Original Medicare Plan – You will probably not need to file a claim form when you have both our Plan and the Original Medicare Plan.

When we are the primary payor, we process the claim first.

When Original Medicare is the primary payor, Medicare processes your claim first. In most cases, your claim will be coordinated automatically and we will then provide secondary benefits for covered charges. To find out if you need to do something to file your claim, call us at 303-338-3600 (toll-free 800-382-4661) in Denver/Boulder, 800-382-4661 in Northern Colorado, and 888-681-7878 in Southern Colorado, (TTY 711), 9 a.m. to 4 p.m., Monday through Friday, or visit our website at kp.org/feds.

We do not waive any costs if the Original Medicare Plan is your primary payor.

You must tell us if you or a covered family member has Medicare coverage, and let us obtain information about services denied or paid under Medicare if we ask. You must also tell us about other coverage you or your covered family members may have, as this coverage may affect the primary/secondary status of this Plan and Medicare.

• Tell us about your Medicare coverage

We offer a program designed to help members with their Medicare Part B premium. This program is called "Senior Advantage 2". For each month you are enrolled in Senior Advantage 2, have Medicare Parts A and B (or Medicare Part B) and are enrolled in Senior Advantage for Federal Members, you will be reimbursed up to $125 (up to $1,500 per year) of your Medicare Part B monthly premium. In addition to reimbursing for the Part B monthly premium, we will cover additional benefits, including lower copayments for office visits, outpatient surgery, inpatient hospital care, emergency care, plus additional coverage for the SilverSneakers® fitness program.

You may enroll in this program if: • You enroll in the Plan’s High or Standard Option. • You enroll in Senior Advantage for Federal Members. • The FEHB subscriber completes an additional application for enrollment in Senior

Advantage 2.

Reimbursements will begin on the first of the month following receipt of your additional application for enrollment in Senior Advantage 2 and we verify your Medicare Part B enrollment. During a calendar year, you may enroll in Senior Advantage 2 only once. If the FEHB subscriber enrolls in Senior Advantage 2, each family member who enrolls in Senior Advantage for Federal Members is required to participate in Senior Advantage 2. If, for any reason, you do not meet the enrollment requirements for Senior Advantage 2, you will no longer be eligible to participate in the program. Your contributions will end and your regular FEHB High or Standard Option benefits will resume. You may be required to repay any reimbursements paid to you in error.

To learn more about Senior Advantage 2 and how to enroll, call us at 800-476-2167 (TTY: 711), 8 a.m. to 8 p.m., 7 days a week, or visit our website at kp.org/feds. We will send you additional information and an additional application for enrollment in Senior Advantage 2.

• Medicare Part B Premium Reimbursement

If you are eligible for Medicare, you may choose to enroll in and get your Medicare benefits from a Medicare Advantage plan. These are private health care choices (like HMOs and regional PPOs) in some areas of the country. To learn more about Medicare Advantage plans, contact Medicare at 800-MEDICARE (800-633-4227) (TTY: 877-486-2048) or at www.medicare.gov.

If you enroll in a Medicare Advantage plan, the following options are available to you:

• Medicare Advantage (Part C)


This Plan and our Medicare Advantage plan: We offer a Medicare Advantage plan known as Kaiser Permanente Senior Advantage for Federal Members. Senior Advantage for Federal Members enhances your FEHB coverage by lowering cost-sharing for some services and/or adding benefits. If you have Medicare Parts A and B, or Medicare Part B only, you can enroll in Senior Advantage for Federal Members with no increase to your FEHB or Kaiser Permanente premium. Your enrollment is in addition to your FEHB High Option or Standard Option enrollment; however, your benefits will be provided under the Kaiser Permanente Senior Advantage for Federal Members plan and are subject to Medicare rules. If you are already a member of Senior Advantage for Federal Members and would like to understand your additional benefits in more detail, please refer to your Senior Advantage for Federal Members Evidence of Coverage. If you are considering enrolling in Senior Advantage for Federal Members, please call us at 800-476-2167 (TTY: 711), 8 a.m. to 8 p.m., 7 days a week, or visit our website at kp.org/feds.

With Kaiser Permanente Senior Advantage for Federal Members, you’ll get more coverage, such as lower cost sharing and better benefits. This 2020 benefit summary allows you to make a side-by-side comparison of your choices:

2020 Benefits and Services

High Option without Medicare

You pay

High Option Senior Advantage 1

You pay

High Option Senior Advantage 2

You pay

Standard Option without Medicare

You pay

Standard Option Senior Advantage 1

You pay

Standard Option Senior Advantage 2

You pay

Deductible None None None $150 None None

Primary care $20 $10 $15 $30 $20 $30

Specialty care $30 $20 $25 $40 $35 $40

Outpatient surgery

$200 $50 $150 $250* $250 $250

Inpatient hospital care

$500 per day up to $1,000

$100/admit $300/admit $750* $250 per day up to $750

$250 per day up to $750

Emergency care

$300 $60 $90 $350* $65 $90

Ambulance $150 $150 $150 $200 $195 $200

Benefit summary continued on next page.


Prescription drugs

Up to a 30-day supply at Plan pharmacies






· Preferred generic

$15 $5 $10 $15 $10 $10

· Preferred brand

$40 $20 $40 $50 $40 $40

· Non-preferred generic/brand

$60 $5/$20 $10/$40 $70 $10/$40 $10/$60

· Specialty $100 $40 $60 $150 $60 $100

Additional benefits offered

Not applicable Eyeglasses and contact lenses allowance and SilverSneakers

SilverSneakers Not applicable SilverSneakers SilverSneakers

Part B Reimbursement

N/A None $125 monthly N/A None $125 monthly

Out-of-pocket maximum (2x per family)

$4,000 per person

$2,400 per person

$2,950 per person

$5,500 per person

$2,950 per person

$3,300 per person

*You pay the deductible, then cost-sharing.

2020 Benefits and Services Basic Option without Medicare

You pay

Basic Option Senior Advantage

You pay

Deductible $500 None

Primary care $20 $20

Specialty care $50 $50

Outpatient surgery 20%* 20%

Benefit summary continued on next page.


Inpatient hospital care 20%* $275 per day up to $1,100

Emergency care 20%* $75

Ambulance 20% up to $500 $235

Prescription drugs Up to a 30-day supply at Plan pharmacies


· Preferred generic $15 $15

· Preferred brand $60 $50

· Non-preferred generic/brand $80 $15/$50

Specialty $200 $75

Additional benefits offered Not applicable SilverSneakers

Part B Reimbursement None None

Out-of-pocket maximum (2x per family)

$6,500 per person $3,400 per person

*You pay the deductible, then cost-sharing.

This Plan and another plan’s Medicare Advantage plan: You may enroll in another plan’s Medicare Advantage plan and also remain enrolled in our FEHB plan. We will still provide benefits when your Medicare Advantage plan is primary, even out of the Medicare Advantage plan’s network and/or service area (if you use our Plan providers). However, we will not waive any of our copayments, coinsurance, or deductibles. If you enroll in a Medicare Advantage plan, tell us. We will need to know whether you are in the Original Medicare Plan or in a Medicare Advantage plan so we can correctly coordinate benefits with Medicare.

Suspended FEHB coverage to enroll in a Medicare Advantage plan: If you are an annuitant or former spouse, you can suspend your FEHB coverage to enroll in a Medicare Advantage plan, eliminating your FEHB premium. (OPM does not contribute to your Medicare Advantage plan premium.) For information on suspending your FEHB enrollment, contact your retirement office. If you later want to re-enroll in the FEHB Program, generally you may do so only at the next Open Season unless you involuntarily lose coverage or move out of the Medicare Advantage plan’s service area.

.

When we are the primary payor, we process the claim first. If you enroll in another plan's Medicare Part D plan and we are the secondary payor, when you fill your prescription at a Plan pharmacy that is not owned and operated by Kaiser Permanente we will review claims for your prescription drug costs that are not covered by Medicare Part D and consider them for payment under the FEHB plan. Our Kaiser Permanente owned and operated pharmacies will not consider another plan's Medicare Part D benefits. These Kaiser Permanente pharmacies will only provide your FEHB Kaiser Permanente benefits.

• Medicare prescription drug coverage (Part D)


You will still need to follow the rules in this brochure for us to cover your care. We will only cover your prescription if it is written by a Plan provider and obtained at a Plan pharmacy or through our Plan mail service delivery program, except in an emergency or urgent care situation.

If you enroll in our Kaiser Permanente Senior Advantage for Federal Members plan, you will get all of the benefits of Medicare Part D plus additional drug benefits covered under your FEHB plan.


Medicare always makes the final determination as to whether they are the primary payor. The following chart illustrates whether Medicare or this Plan should be the primary payor for you according to your employment status and other factors determined by Medicare. It is critical that you tell us if you or a covered family member has Medicare coverage so we can administer these requirements correctly. (Having coverage under more than two health plans may change the order of benefits determined on this chart.)

Primary Payor Chart A. When you - or your covered spouse - are age 65 or over and have Medicare and you... The primary payor for the

individual with Medicare is... Medicare This Plan

1) Have FEHB coverage on your own as an active employee 2) Have FEHB coverage on your own as an annuitant or through your spouse who is an

annuitant 3) Have FEHB through your spouse who is an active employee 4) Are a reemployed annuitant with the Federal government and your position is excluded from

the FEHB (your employing office will know if this is the case) and you are not covered under FEHB through your spouse under #3 above

5) Are a reemployed annuitant with the Federal government and your position is not excluded from the FEHB (your employing office will know if this is the case) and... • You have FEHB coverage on your own or through your spouse who is also an active employee

• You have FEHB coverage through your spouse who is an annuitant 6) Are a Federal judge who retired under title 28, U.S.C., or a Tax Court judge who retired

under Section 7447 of title 26, U.S.C. (or if your covered spouse is this type of judge) and you are not covered under FEHB through your spouse under #3 above

7) Are enrolled in Part B only, regardless of your employment status for Part B services

for other services

8) Are a Federal employee receiving Workers' Compensation disability benefits for six months or more

*

B. When you or a covered family member... 1) Have Medicare solely based on end stage renal disease (ESRD) and...

• It is within the first 30 months of eligibility for or entitlement to Medicare due to ESRD (30-month coordination period)

• It is beyond the 30-month coordination period and you or a family member are still entitled to Medicare due to ESRD

2) Become eligible for Medicare due to ESRD while already a Medicare beneficiary and... • This Plan was the primary payor before eligibility due to ESRD (for 30 month coordination period)

• Medicare was the primary payor before eligibility due to ESRD 3) Have Temporary Continuation of Coverage (TCC) and...

• Medicare based on age and disability • Medicare based on ESRD (for the 30 month coordination period) • Medicare based on ESRD (after the 30 month coordination period)

C. When either you or a covered family member are eligible for Medicare solely due to disability and you...

1) Have FEHB coverage on your own as an active employee or through a family member who is an active employee

2) Have FEHB coverage on your own as an annuitant or through a family member who is an annuitant

D. When you are covered under the FEHB Spouse Equity provision as a former spouse *Workers' Compensation is primary for claims related to your condition under Workers' Compensation.


Section 10. Definitions of Terms We Use in This Brochure

January 1 through December 31 of the same year. For new enrollees, the calendar year begins on the effective date of their enrollment and ends on December 31 of the same year.

Calendar year

An approved clinical trial includes a phase I, phase II, phase III, or phase IV clinical trial that is conducted in relation to the prevention, detection, or treatment of cancer or other life-threatening disease or condition and is either Federally funded; conducted under an investigational new drug application reviewed by the Food and Drug Administration; or is a drug trial that is exempt from the requirement of an investigational new drug application. • Routine care costs – costs for routine services such as doctor visits, lab tests, x-rays

and scans, and hospitalizations related to treating the patient’s condition whether the patient is in a clinical trial or is receiving standard therapy.

• Extra care costs – costs related to taking part in a clinical trial such as additional tests that a patient may need as part of the trial, but not as part of the patient’s routine care.

• Research costs – costs related to conducting the clinical trial such as research physician and nurse time, analysis of results, and clinical tests performed only for research purposes. These costs are generally covered by the clinical trials. This plan does not cover these costs.

Clinical trials cost categories

Coinsurance is the percentage of our allowance that you must pay for your care. See Section 4.

Coinsurance

A copayment is a fixed amount of money you pay when you receive covered services. See Section 4.

Copayment

Cost-sharing is the general term used to refer to your out-of-pocket costs (e.g., deductible, coinsurance, and copayments) for the covered care you receive.

Cost-sharing

Care we provide benefits for, as described in this brochure. Covered services

(1) Assistance with activities of daily living, for example, walking, getting in and out of bed, dressing, feeding, toileting, and taking medication. (2) Care that can be performed safely and effectively by people who, in order to provide the care, do not require medical licenses or certificates or the presence of a supervising licensed nurse. Custodial care that lasts 90 days or more is sometimes known as long-term care.

Custodial care

A deductible is a fixed amount of covered expenses you must incur for certain covered services and supplies before we start paying benefits for those services. See Section 4.

Deductible

We do not cover a service, supply, item or drug that we consider experimental. We consider a service, supply, item, or drug to be experimental when the service, supply, item or drug:

(1) has not been approved by the FDA; or

(2) is the subject of a new drug or new device application on file with the FDA; or

(3) is part of a Phase I or Phase II clinical trial, as the experimental or research arm of a Phase III clinical trial; or is intended to evaluate the safety, toxicity, or efficacy of the service; or

(4) is available as the result of a written protocol that evaluates the service’s safety, toxicity, or efficacy; or

(5) is subject to the approval or review of an Institutional Review Board; or

Experimental or investigational service


(6) requires an informed consent that describes the service as experimental or investigational.

We carefully evaluate whether a particular therapy is safe and effective or offers a reasonable degree of promise with respect to improving health outcomes. The primary source of evidence about health outcomes of any intervention is peer-reviewed medical or dental literature.

Health care benefits that are available as a result of your employment, or the employment of your spouse, and that are offered by an employer or through membership in an employee organization. Health care coverage may be insured or indemnity coverage, self-insured or self-funded coverage, or coverage through health maintenance organizations or other managed care plans. Health care coverage purchased through membership in an organization is also "group health coverage."

Group health coverage

A physician or other health care professional licensed, accredited, or certified to perform specified health services consistent with state law.

Health care professional

All benefits need to be medically necessary in order for them to be covered benefits. Generally, if your Plan physician provides the service in accord with the terms of this brochure, it will be considered medically necessary. However, some services are reviewed in advance of you receiving them to determine if they are medically necessary. When we review a service to determine if it is medically necessary, a Plan physician will evaluate what would happen to you if you do not receive the service. If not receiving the service would adversely affect your health, it will be considered medically necessary. The services must be a medically appropriate course of treatment for your condition. If they are not medically necessary, we will not cover the services. In case of emergency services, the services that you received will be evaluated to determine if they were medically necessary.

Medically necessary

Certain Hospital Acquired Conditions, as defined by Medicare, including things like wrong-site surgeries, transfusion with the wrong blood type, pressure ulcers (bedsores), falls or trauma, and nosocomial infections (hospital-acquired infections) associated with surgeries or catheters, that are directly related to the provision of an inpatient covered service at a Plan provider.

Never event/serious reportable event

Our allowance is the amount we use to determine our payment and your coinsurance for covered services. We determine our allowance as follows: • For services and items provided by Kaiser Permanente, the applicable charges in the

Plan’s schedule of Kaiser Permanente charges for services and items provided to Plan members.

• For services and items for which a provider (other than Kaiser Permanente) is compensated on a capitation basis, the charges in the schedule of charges that Kaiser Permanente negotiates with the capitated provider.

• For items obtained at a pharmacy owned and operated by Kaiser Permanente, the amount the pharmacy would charge a Plan member for the item if a Plan member’s benefit plan did not cover the item. This amount is an estimate of: the cost of acquiring, storing, and dispensing drugs, the direct and indirect costs of providing Kaiser Permanente pharmacy services and items to Plan members, and the pharmacy program’s contribution to the net revenue requirements of the Plan.

• For all other services and items, the payments that Kaiser Permanente makes for the services and items or, if Kaiser Permanente subtracts cost-sharing from its payment, the amount Kaiser Permanente would have paid if it did not subtract cost-sharing.

Our allowance

Any claims that are not pre-service claims. In other words, post-service claims are those claims where treatment has been performed and the claims have been sent to us in order to apply for benefits.

Post-service claims


Those claims (1) that require precertification, prior approval, or a referral and (2) where failure to obtain precertification, prior approval, or a referral results in a reduction of benefits.

Pre-service claims

A carrier's pursuit of a recovery if a covered individual has suffered an illness or injury and has received, in connection with that illness or injury, a payment from any party that may be liable, any applicable insurance policy, or a worker's compensation program or insurance policy, and the terms of the carrier's health benefits plan require the covered individual, as a result of such payment, to reimburse the carrier Charges for Covered Services out of the payment to the extent of the Covered Services provided. The right of reimbursement is cumulative with and not exclusive of the right of subrogation.

Reimbursement

A carrier's pursuit of a recovery from any party that may be liable, any applicable insurance policy, or a worker's compensation program or insurance policy, as successor to the rights of a covered individual who suffered an illness or injury and has obtained benefits from that carrier's health benefits plan.

Subrogation

A claim for medical care or treatment is an urgent care claim if waiting for the regular time limit for non-urgent care claims could have one of the following impacts: • Waiting could seriously jeopardize your life or health; • Waiting could seriously jeopardize your ability to regain maximum function; or • In the opinion of a physician with knowledge of your medical condition, waiting

would subject you to severe pain that cannot be adequately managed without the care or treatment that is the subject of the claim.

Urgent care claims involve Pre-service claims and not Post-service claims. We will determine whether or not a claim is an urgent care claim by applying the judgment of a prudent layperson who possesses an average knowledge of health and medicine.

If you believe your claim qualifies as an urgent care claim, please contact Member Services at 303-338-3800 or toll-free 800-632-9700 in Denver/Boulder, 844-201-5824 in Northern Colorado, and 888-681-7878 in Southern Colorado. You may also prove that your claim is an urgent care claim by providing evidence that a physician with knowledge of your medical condition has determined that your claim involves urgent care.

Urgent care claims

Us and We refer to Kaiser Foundation Health Plan of Colorado. Us/We

You refers to the enrollee and each covered family member. You


Index

Do not rely on this page; it is for your convenience and may not show all pages where the terms appear. 24-hour advice line ........................60-61, 73 Accidental injury to teeth ........................72 Allergy care ................................................37 Alternative treatments (acupuncture) ........46 Ambulance ................................18-20, 59, 63 Anesthesia ..................................................55 Bariatric surgery .....................18-20, 48-50 Binding arbitration .....................................80 Biopsy ...................................................48-50 Blood and blood products .....................56-58 Breast cancer screening ........................30-32 Calendar year ...........................................23 Catastrophic protection out-of-pocket maximum ..............................................23-24 Centers of Excellence ................................73 CHAMPVA ................................................84 Changes for 2020 .......................................15 Chemotherapy ...........................37-38, 68-70 Chiropractic services ..................................46 Cholesterol tests ....................................30-32 Claims

Disputed claims/Appeals ................81-83 Filing a claim ..................................79-80

Clinical trials ........................................87, 95 Coinsurance ..........................................23, 95 Colorectal cancer screening ..................30-32 Congenital anomalies ...........................48-51 Contraceptive drugs and devices ..........68-70 Coordination of benefits .......................84-94 Copayment ...........................................23, 95 Cost-sharing .........................................23, 95 Covered services ........................................95 Custodial care .............................................95 Deaf and hearing-impaired services .......73 Deductible ............................................23, 95 Definitions ............................................95-97 Dental ...................................................72, 77 Dependent coverage outside the service area

..............................................................74 Diabetic equipment and supplies ...18-20,

43-45, 68-70 Diagnostic tests ...................18-20, 30, 57-58 Dialysis ......................................37-38, 43-45 Durable medical equipment (DME) ...18-20,

43-45 Early childhood intervention services ...39-

-40 Educational classes and programs .............47 Emergency ......................................21, 60-63 Enrollment ....................................................8 Exclusions, general ....................................78 Experimental or investigational services

..................................................78, 95-96

Eyeglasses ..................................................41 Family planning .......................................35 Fecal occult blood tests .........................30-32 Federal Dental and Vision Insurance Program (FEDVIP) ....................................86 Federal Flexible Spending Account Program (FSAFEDS) ................................................22 Flexible benefits option ..............................73 Foot care ...............................................41-42 Fraud .........................................................3-4 Genetic counseling ........................18-20, 35 Group health coverage ...............................96 Gynecological care ...............................29-30 Health care professional ..........................96 Hearing aids ...............................................40 Hearing services .........................................40 Home health services ................18-20, 45-46 Hospice care ..............................18-20, 58-59 Hospital

Facility charges .........................56-57, 65 Physician charges ...........................29-30

Imaging (CT, MRI, PET scans) ...18-20, 30, 60

Immunizations ......................................30-33 Infertility .........................................18-20, 36 Inhalation therapy .................................37-38 Insulin ............................18-20, 43-45, 68-70 Intravenous (IV)/Infusion Therapy .......37-38 Laboratory tests ............................30, 56-57 Language interpretation services ..........13-14 Mammograms .....................................30-32 Maternity care .......................................34-35 Medicaid ....................................................84 Medically necessary .......................18-20, 96 Medicare ...........................................1, 87-90 Mental health ........................................64-66 Never event ........................................5-7, 96 Newborn care ........................................34-35 Non-FEHB benefits ...................................77 Nuclear medicine .................................30, 60 Obstetrical care ...................................34-35 Occupational therapy .................18-20, 38-39 Options for care ..........................................73 Orthopedic devices ....................18-20, 42-43 Our allowance ............................................96 Out-of-pocket expenses ........................23-24 Oxygen ......................................18-20, 43-45 Pap test .................................................30-32 Physical examinations ..........................29-47 Physical therapy ........................18-20, 38-39 Physician services

Primary care ..............................17, 29-47 Specialty care ......................17-18, 29-47

Post-service claims ...............................79, 96 Pre-service claims ......................................97 Prescription drugs .................................67-71

Mail order .......................................67-68 Preventive care

Adult ...............................................30-32 Children ..........................................32-33

Prior approval .......................................18-20 Prostate cancer screening ......................30-32 Prosthetic devices ...........18-20, 42-43, 48-50 Radiation therapy ...............................37-38 Rates .....................................................3, 102 Rehabilitation ............................18-20, 38-39 Respiratory therapy ...............................37-38 Rewards ................................................75-76 Room and board ....................................56-58 Service area .........................................13-14 Skilled nursing facility care ............18-20, 58 Speech therapy ................................18-20, 39 Sterilization procedures ..................35, 48-50 Subrogation .....................................85-86, 97 Substance use disorder ..........................64-66 Surgery

Inpatient facility ..................18-20, 48-55 Oral and Maxillofacial .........................51 Outpatient facility ................18-20, 48-55 Physician charges ...........................48-55 Reconstructive ................................50-51

Syringes ................................................68-70 Temporary Continuation of Coverage

........................................................11-12 Therapy (See specific type) Tobacco cessation/E-cigarettes ...30-32, 47,

68-70 Transplants ................................18-20, 52-55 Travel benefit ........................................74-75 Treatment therapies ...................18-20, 37-38 TRICARE ..................................................84 Urgent care ..........................................61-62 Urgent care claims ...............................20, 97 Us/We .........................................................97 Vision services ..........................................41

Eye exam ..............................................41 Visiting Member ........................................74 Weight management

Drugs ..............................................68-70 Programs ...................................18-20, 47

Well-child care ......................................32-33 Wheelchairs ..........................................43-45 Workers’ Compensation .............................84 X-rays (including CT, MRI, PET scans)

..................................................18-20, 30 You .........................................................3, 97

98 2020 Kaiser Foundation Health Plan of Colorado Index

Summary of Benefits for the High Option of Kaiser Foundation Health Plan of Colorado - 2020

• Do not rely on this chart alone. All benefits are provided in full unless indicated and are subject to the definitions, limitations, and exclusions in this brochure. You can obtain a copy of our Summary of Benefits and Coverage at kp.org/feds. On this page we summarize specific expenses we cover; for more detail, look inside.

• If you want to enroll or change your enrollment in this Plan, be sure to put the correct enrollment code from the cover on your enrollment form.

• We only cover services provided or arranged by Plan providers, except in emergencies.

• The High Option has no deductible.

High Option Benefits You pay Page Medical services provided by physicians:

$20 per primary care office visit $30 per specialty care office visit

29 • Diagnostic and treatment services provided in the office

Services provided by a hospital:

$500 per day up to $1,000 maximum per admission, except nothing for maternity care delivery

56 • Inpatient

$200 per visit 57 • Outpatient

Emergency benefits:

$300 per visit 61 • In-area

$300 per visit 62 • Out-of-area

Regular cost-sharing 64 Mental health and substance use disorder treatment:

$15 preferred generic drugs; $40 preferred brand-name drugs; $60 non-preferred drugs; $100 specialty drugs

68 Prescription drugs:

All charges 72 Diagnostic and preventive dental care:

Eye exam; $20 per primary care office visit; $30 per specialty care office visit

41 Vision care:

. 73 Special features: Flexible benefits option; 24 hour advice line; Centers of Excellence; Services from other Kaiser Permanente regions; Dependent coverage outside the service area; Travel benefit; Rewards

Nothing after $4,000 per person or $8,000 per family enrollment per year. Some costs do not count toward this protection.

23 Protection against catastrophic costs (out-of-pocket maximum):

99 2020 Kaiser Foundation Health Plan of Colorado High Option Summary

Summary of Benefits for the Standard Option of Kaiser Foundation Health Plan of Colorado - 2020

• Do not rely on this chart alone. All benefits are provided in full unless indicated and are subject to the definitions, limitations, and exclusions in this brochure. You can obtain a copy of our Summary of Benefits and Coverage at kp.org/feds. On this page we summarize specific expenses we cover; for more detail, look inside.



• Below, an asterisk (*) means the item is subject to the $150 per person ($300 per family) calendar year deductible.

Standard Option Benefits You Pay Page Deductible:

$150 per person and $300 per family 23 • Covered services

Medical services provided by physicians:

$30 (nothing for children through age 17) per primary care visit $40 per specialty care visit



$750 per admission*, except nothing for maternity care delivery

56 • Inpatient

$250* 57 • Outpatient

Emergency benefits:

$350* 61 • In-area

$350* 62 • Out-of-area






41 Vision care:




100 2020 Kaiser Foundation Health Plan of Colorado Standard Option Summary

Summary of Benefits for the Basic Option of Kaiser Foundation Health Plan of Colorado - 2020

• Do not rely on this chart alone. All benefits are provided in full unless indicated and subject to the definitions, limitations, and exclusions in this brochure. You can obtain a copy of our Summary of Benefits and Coverage at kp.org/feds. On this page we summarize specific expenses we cover; for more detail, look inside.



• Below, an asterisk (*) means the item is subject to the $500 per person ($1,000 per family) calendar year deductible.

Basic Option Benefits You pay Page Deductible:

$500 per person and $1,000 per family 23 • Covered services

Medical services provided by physicians:

$20 per primary care visit

$50 per specialty care visit



20% of our allowance* 56 • Inpatient

20% of our allowance * 57 • Outpatient

Emergency benefits:

20% of our allowance* 61 • In-area:

20% of our allowance* 62 • Out-of-area






41 Vision care:




101 2020 Kaiser Foundation Health Plan of Colorado Basic Option Summary

2020 Rate Information for Kaiser Foundation Health Plan of Colorado

To compare your FEHB health plan options please go to www.opm.gov/fehbcompare.

To review premium rates for all FEHB health plan options please go to www.opm.gov/FEHBpremiums or www.opm.gov/Tribalpremium.

Non-Postal rates apply to most non-Postal employees. If you are in a special enrollment category, contact the agency that maintains your health benefits enrollment.

Postal rates apply to certain United States Postal Service employees as follows:

• Postal Category 1 rates apply to career bargaining unit employees who are represented by the following agreements: APWU, IT/AS, NALC, and NPMHU.

• If you are a career bargaining unit employee represented by the agreement with NPPN, you will find your premium rates on https://liteblue.usps.gov/fehb.

• Postal Category 2 rates apply to career bargaining unit employees who are represented by the following agreement: PPOA.

Non-Postal rates apply to all career non-bargaining unit Postal Service employees and career employees represented by the NRLCA agreement. Postal rates do not apply to non-career Postal employees, Postal retirees, and associated members of any Postal employee organization who are not career Postal employees.

If you are a Postal Service employee and have questions or require assistance, please contact:

USPS Human Resources Shared Service Center: 877-477-3273, option 5, Federal Relay Services: 800-877-8339

Premiums for Tribal employees are shown under the monthly non-Postal column. The amount shown under employee contribution is the maximum you will pay. Your Tribal employer may choose to contribute a higher portion of your premium. Please contact your Tribal Benefits Officer for exact rates.

Type of Enrollment Enrollment Code

Non-Postal Premium Postal Premium Biweekly Monthly Biweekly

Gov't Share

Your Share

Gov't Share

Your Share

Category 1 Your Share

Category 2 Your Share

High Option Self Only 651 $235.77 $128.46 $510.84 $278.33 $125.18 $115.36

High Option Self Plus One 653 $504.12 $319.04 $1,092.26 $691.25 $312.04 $291.03

High Option Self and Family 652 $546.47 $276.69 $1,184.02 $599.49 $269.10 $246.34

Standard Option Self Only 654 $232.37 $77.46 $503.48 $167.82 $74.36 $64.29

Standard Option Self Plus One 656 $504.12 $196.09 $1,092.26 $424.86 $189.09 $168.08

Standard Option Self and Family 655 $525.16 $175.05 $1,137.84 $379.28 $168.05 $145.29

Basic Option Self Only N41 $167.81 $55.93 $363.58 $121.19 $53.70 $46.43

Basic Option Self Plus One N43 $379.25 $126.41 $821.70 $273.90 $121.36 $104.92

Basic Option Self and Family N42 $379.25 $126.41 $821.70 $273.90 $121.36 $104.92

102 2020 Kaiser Foundation Health Plan of Colorado

a health maintenance organization (high, standard, and basic … · 2019-10-13 · northern...

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